Central Heights Elementary

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Bullying Incident Report

Are you being bullied, harassed, or picked on? Do you know someone else who may be? You can use the form to ANONYMOUSLY report what is going on. All reports will be kept confidential if that is what you want.

The District prohibits bullying on school property, at school-sponsored or school-related activities, or in any vehicle operated by the District. Bullying may include verbal or written expression, expression through electronic means, or physical conduct. Bullying is not tolerated by the District, and any student or parent of a student who believes that the student or another student has experienced bullying or that a student has engaged in bullying is encouraged to immediately report the incident. Retaliation against anyone involved in the reporting process is a violation of District policy and is prohibited.

Students or parents may report an alleged incident of bullying, orally or in writing, to a teacher, counselor, principal or other District employee. Students or parents may contact the District to obtain an incident report form that may be used to submit the report.

ANONYMOUS Bullying Incident Report

Date of Incident:

Date of Report:

Who was the person(s) engaged in bullying?

Grade of person(s) who engaged in bullying?

Who was being bullied?

Grade of person who was being bullied?

What type of bullying?

Physical

Emotional/Social

Damage to Property

Online

Other:

Other location details: (Please explain the specific location details such as which hallway, where on the Internet, what restroom, etc)

Describe what happened with as many details as possible.

Person reporting the incident:(OPTIONAL). Please use your full name.

May we contact you for more information on this incident?

Yes

Thank you for reporting this incident. We appreciate your concern. When you click "Submit Form" this will be sent to the campus administrator.

Email a copy to

optional

Required Fields

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