Name of Individual Filing Complaint:
Phone Number:
E-Mail Address:
Physical Address:
Name of Student or Staff Member in which bullying or harassing behavior is being directed:
School (Control + Click to choose multiple schools)
Grade:
Teacher (Homeroom):
Possible Motivation for Bullying/Harassment:
(Use control and click multiple selections)
If Other, please enter it here:
Description of the Incident:
Names of individuals involved:
Names of Witnesses and Bystanders:
Security Measure