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Bullying/Harassment Complaint Form
(Students May Report Anonymously)
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* Indicates required question
Email
*
Your email
Date Filed:
*
MM
/
DD
/
YYYY
First and last name of student being bullied/harassed:
Your answer
School Site of student being bullied/harassed:
*
Choose
Bemis Elementary
Boyd Elementary
Carter High
Casey Elementary
Curtis Elementary
Dollahan Elementary
Dunn Elementary
Eisenhower High
Fitzgerald Elementary
Frisbie Middle
Garcia Elementary
Henry Elementary
Hughbanks Elementary
Jehue Middle
Kelley Elementary
Kolb Middle
Kordyak Elementary
Kucera Middle
Milor High
Morgan Elementary
Morris Elementary
Myers Elementary
Preston Elementary
Rialto High
Rialto Middle
Simpson Elementary
Trapp Elementary
Werner Elementary
Zupanic High
Address of student being bullied/harassed:
Your answer
Phone # of student being bullied/harassed:
Your answer
Please identify yourself:
Student
Parent/Guardian
Employee
Volunteer
Other
Please check the type of bullying that has occurred (more than one can be checked):
Verbal Abuse (name-calling, racial remarks, belittling, etc. Can be done over the phone, in writing, in person, text, email)
Physical (hitting, kicking, shoving, twisting limbs, spitting, or destroying personal belongings)
Extortion (verbal or physical bullying for money or personal time)
Hazing (having to participate in an act of physical or emotional harm to be part of a group, or are a victim of a group)
Indirect Bullying (rejection, exclusion, ignoring, alienating, or isolating to purposely cause emotional distress)
Cyberbullying (using technology to harass, threaten, or target another person - text, IMs, email, Facebook, videos, MySpace, Twitter, etc.
Bullying/Harassment on the basis of:
*
Race, color or nationality
Gender or Gender Identity
Disability
Other:
Required
Dates of alleged bullying or harassment
Your answer
Person(s) alleged to have committed the bullying or harassment:
Your answer
Description of the incident: If possible, use specific dates, times, locations, names, etc.
Your answer
Names of witnesses:
Your answer
Have you reported this incident to anyone else:
Yes
No
Clear selection
If yes, who did you report the incident to:
Your answer
Name of Reporting Person
*
Your answer
Date:
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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