Bullying, Harassment, or Intimidation Reporting Form


The Bullying, Harassment or Intimidation Reporting Form should be used to report alleged incidents of bullying, harassment, or intimidation that occurred during the current school year on school property, at a school-sponsored activity or event off school property, on a school bus, on the way to and/or from school, or through electronic communication on or off school property. School staff will address incidents that occur at school or have a connection or nexus back to the school setting that create a risk of harm to other students while they are at school or interfere with the educational environment.

If you are a student, the parent/guardian or caregiver of a student, a close adult relative of a student, a school staff member, or a bystander and wish to report an incident of alleged bullying, cyberbullying, harassment, or intimidation, please complete this form, and return it to the school principal.

You may contact the school for additional information or assistance at any time. (Bullying, cyberbullying, harassment, and intimidation definitions are provided below.)


Bullying– is unwanted, demeaning behavior among students that involves a real or perceived power imbalance. The behavior is repeated, or is highly likely to be repeated, over time. In order to be considered bullying, the behavior must be intentional and include: 1) An imbalance of power (students who bully use their physical, emotional, social, or academic power to control, exclude, or harm others), and 2) Repetition (bullying behaviors happen more than once or are highly likely to be repeated based on evidence gathered).

Cyberbullying– is bullying that takes place over digital devices like cell phones, computers, and tablets. Cyberbullying can occur through texting, apps, or online via social media, forums, or gaming where people can view, participate in, or share content. Cyberbullying includes sending, posting, or sharing negative, harmful, false, or hurtful content about another student. It can include sharing personal or private information about someone else causing embarrassment or humiliation.

Harassment – includes actual or perceived negative actions that offend, ridicule, or demean another student with regard to race, ethnicity, national origin, immigration status, family/parental or marital status, sex, sexual orientation, gender identity, gender expression, religion, ancestry, physical attributes, socioeconomic status, physical or mental ability, or disability.

Intimidation – is any communication or action directed against another student that threatens or induces a sense of fear and/or inferiority. Retaliation may be considered a form of intimidation.

Bullying, Harassment or Intimidation Reporting Form

30 Questions

Please complete this form in its entirety before submission. Your submission will be sent to your school's administration team and the Student Services Department.

Where do the students involved in this report attend school?

First & Last Name

Parent/Guardian/Caregiver of a Student
Close adult relative of a student
School Staff

If there were multiple incidents on different dates, enter them in Q18 and Q19

Choose all that apply

Check all boxes that apply

On school property
On the way to/from school
On a school bus
Off school property or at a school-sponsored activity or event
Digital device on school property
Digital device off school property
During virtual learning
Yes, but it did not require medical attention
Yes, and it required medical attention
Yes, but psychological services have not been sought
Yes, and psychological services have been sought