Editing previous response:

Please fix the highlighted areas below before submitting.

Bullying Report Form

Potential Bullying Report Form

Note to Person Reporting: This form will be confidentially maintained in accordance with the Family Educational rights and Privacy Act ("FERPA"), and generally will not be shared with anyone except those working to investigate or respond to the report. It's NOT MANDATORY to provide your name when completing this report. Please return completed forms to any campus Main office. Anonymous forms may be place in a sealed envelope and given to campus Principal or designee.

Answer Required

Cedar Hill

Prichard

Scyene

Contact Information

Name of Person Submitting Report (NOT REQUIRED) AND GRADE LEVEL

Answer Required

Name of Potential Victim and grade level*

Answer Required

Name of Potential Bully and grade level*

Answer Required

Name of Witness and grade level*

Answer Required

Date of Incident*

Answer Required

Time*

Answer Required

Location of Incident:*

Answer Required

What Happened? Describe what happened: (Additional information may be attached to support this form)*

Answer Required

Please tell us if physical force or threats were used, or if cyber bullying was involved. Please describe*

Answer Required

What did the potential victim do?*

Answer Required

Was anyone else involved? If so, who?*

Answer Required

Were there any witnesses? If so, who?*

Answer Required

How often has this happened?*

Answer Required

Describe what happened immediately before the incident?*

Answer Required

Have you previously reported this to anyone? If so, who?*

Answer Required

Confirmation Email

Email Required