Bullying Report Form

Bullying Report Form
This form is to be confidentially maintained in accordance with the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g.
Do not file in the cumulative record.

OTSELIC VALLEY CENTRAL SCHOOL DISTRICT
INCIDENT REPORTING FORM

Name of student target:
Age:
Grade:
Name(s) of alleged aggressor(s) (If known):
Age:
Grade:
Name of witness(es) (If known)
If "other," explain here:
Where did the incident (s) happen? Choose all that apply:





If "other," explain here:
What best describes what happened? Choose all that apply:










If "other," explain here:
Did a physical injury result from this incident?


Is there any additional information you would like to provide?
What did the alleged aggressor(s) say or do?
Name of person reporting incident (optional):
Telephone (optional):
Email (optional):
I am a (select one):


To validate your submission, please answer the following math problem:

8 + 5 =
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