(Bullying and/or Cyberbullying) Name: _______________________________ Student ID: _______________________ Grade: ______ Date: ______________ Time: _________ School: ___________________________________________ Please answer the following questions about this reporting incident: List the name of the alleged bully, and/or cyberbully. If name is not known, provide any other identifiable information: Relationship between you and the alleged bully, and/or cyberbully: Describe the incident: ________________________________________________________________________ When and where did it happen? _______________________________________________________________ Were there any witnesses? [ ] yes [ ] no If yes, who? ___________________________________ Other information, including previous incidents or threats: Student or parent declines to complete this form: Initial: _________________ Date: ____________ I certify that all statements made in the complaint are true and complete. Any intentional false
(Bullying and/or Cyberbullying) Name: _______________________________ Student ID: _______________________ Grade: ______ Date: ______________ Time: _________ School: ___________________________________________ Please answer the following questions about this reporting incident: List the name of the alleged bully, and/or cyberbully. If name is not known, provide any other identifiable information: Relationship between you and the alleged bully, and/or cyberbully: Describe the incident: ________________________________________________________________________ When and where did it happen? _______________________________________________________________ Were there any witnesses? [ ] yes [ ] no If yes, who? ___________________________________ Other information, including previous incidents or threats: Student or parent declines to complete this form: Initial: _________________ Date: ____________ I certify that all statements made in the complaint are true and complete. Any intentional false
Parent-and-Student-Handbook-2017-18%20A.docx