Is this a repeat infraction? Yes | No | Unknown
Name of School Where Student(s) Attend:
Location of Incident (check all that apply):
Type of Incident (Check Appropriate Boxes)
Bullying Behaviors (Check all that apply):
Cyber-bullying using:
Harassment (Check Purpose):
Describe the incident (attach a separate sheet of paper if necessary):
Do you have any physical evidence?
Name of Person Completing Report (OPTIONAL):
May we contact you for further information?YES / NO
If Yes, which is the best way to contact you?PHONE / TEXT / EMAIL
Phone Number: HOME / CELL
Email Address: