Directions:
Please answer these questions as honestly and specifically as you can and return this completed form to your child’s school principal. The situation will be handled as confidentially as possible.
School: _____________________________
Person Reporting: ____________________________________________ Grade: ______ Date: __________________
If the person reporting is the witness, who is being bullied/harassed?______________________ Grade: ______
1. Who is harassing/bullying you? _____________________________________________________________________
2. What has happened?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. Where did it happen?_____________________________________________________________________________
4. Witness/es name/s (if any): ____________________________________________________ Grade: ____________
5. How long has this been going on?_________________________________________________________________
6. What have you done about this problem? _________________________________________________________________________________________________________________________________________________________________________________________________
7. Have you talked to anyone about this already? (Student, Teacher, Other Adult)
__ Yes Name: __________________________________
__ No
8. Who do you want to talk to about the problem? ___________________________________________________
9. What do you want to happen now?
__ I just want someone to know.
__ I want an adult to talk to the person who is harassing/bullying me.
__ I want an adult to help me and the person/s doing the harassing/bullying to solve the problem.
__ I want an adult to try to stop the bullying/harassment.
****************************PRINCIPAL/STAFF FOLLOW UP*******************************
______________ Date I met with the reporting student.
______________ Date I followed up with person/s doing the harassing.
______________ Date I followed up with reporting student.
X ____________________________________________ _________________
Principal/Staff Signature Date
A staff person has met with me about the resolution of this incident.
X_____________________________________________ __________________
Reporting Student Signature Date
This report and follow-up will be kept on file in the above principal’s office and entered in the student information management system to provide a cumulative record.
Log of follow-up on this incident:
_________________________________________________________________________________________________________________________________________________________________________________________________
Note of interview with person/s reported to doing the harassing/bullying:
_________________________________________________________________________________________________________________________________________________________________________________________________
Notes of the interview with the reporter:
_________________________________________________________________________________________________________________________________________________________________________________________________
Consequence Component:
__ Verbal Warning
__ In/Out of School Suspension
__ Mediation
__ Parent/Guardian Contact
__ In-School Detention
__ Citation Issued
__ School Principal Hearing
__ Pre-Expulsion Discipline Hearing
__ Expulsion
__ Other______________________
Social Learning Component:
_________________________________________________________________________________________________________________________________________________________________________________________________
Restitution / Restorative Component:
_________________________________________________________________________________________________________________________________________________________________________________________________
________Date/initial filed and entered in the student information system.
________Date/initial if this is a report of sexual harassment: it must be reported to the Title IX Coordinator.
