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Bullying/Harassment Form

September 06, 2013

When looking at the totality of the circumstances, harassment and bullying mean any electronic, written, verbal, or physical act or conduct toward a student which is based on any actual or perceived trait or characteristic of the student and which creates an objectively hostile school environment that meets one or more of the following conditions:

  • Places the student in reasonable fear of harm to the student's person or property;
  • Has a substantially detrimental effect of the student's physical or mental health;
  • Has the effect of substantially interfering with the student's academic performance; or
  • Has the effect of substantially interfering with the student's ability to participate in or benefit from the services, activities, or privileges provided by a school.

Please use this form for reporting information about bullying you have witnessed:

Bullying/Harassment Form


Name*: (person reporting incident)

E-mail Address:

Date of bullying incident:

Time of day of incident:  

Location of incident*:

Other possible witnesses:  

Who was being bullied*?  

(If you do not know the victim's name, please provide whatever information you can to assist us such as an age estimate, physical description, etc.)


Who was doing the bullying*?

Nature of Discrimination or Harassment Alleged (Check all that apply)

Age                            Physical Attribute                Sex

Disability                     Physical/Mental Ability         Sexual Orientation

Family Status              Political Belief                      Socio-economic Background

Gender Status              Political Party Preference      Other

Marital Status                Race/Color                        

National Origin/Ethnic     Religion/Creed


Details/Description of incident*:


(*Indicates a field that must be filled out to submit this form)


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