Bullying Report Form

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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:

On school property
On a school bus
At a school-sponsored activity/event off school property
On the way to/from school
Online/via technology
Other

If "other," explain here:

What best describes what happened? Choose all that apply:

Teasing
Social exclusion
Retaliation
Threat/property damage
Intimidation
Sexual harassment
Stalking
Physical violence
Theft/property damage
Public humiliation
Other

If "other," explain here:

Did a physical injury result from this incident?

No
Yes, but it did not require medical attention
Yes, and it required medical attention

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):

Student
Parent
Guardian

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