Form for Reporting Alleged Bullying Incidents

Your Name Your Name First Last
Phone Number Phone Number - ### - ### ####
Your Email
Your School
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of Parent or Guardian Name of Parent or Guardian First Last
Date that you are filing report: Date that you are filing report: / MM / DD YYYY
Date of Incident Date of Incident / MM / DD YYYY
Time mof Incident Time mof Incident : HH MM AM/PM
Locations of Alleged Incident:
Witnesses of Incident
Student(s) Initiating Bullying/Harassment
Name Name First Last
Grade
School
Name Name First Last
Grade
School
Student(s) Being Targeted Bullied
Name Name First Last
Grade
School
Describe the Incidents:
Checkboxes

Checkboxes Verbal (Name Calling, Taunting/Ridiculing, Demeaning Comments, Threatening, Intimidation) Physical (Hitting/Kicking, Pushing/Shoving, Inappropriate Touching, Spitting, Damaging/Stealing Property, Inappropriate Gesturing, Intimidation) Electronic or Written Communication (Writing/Graffiti, Texting, Email, Social Network, Video, Intimidation) Social/Relational (Staring/Leering, Spreading Rumors, Embarrassing Someone in Public) Combination (more than one of the above)
How might the school prevent future occurrences?
Note: The School City of Hammond is not authorized to disclose to a target, private educational or personnal data regarding an alleged perpetrator who is a student or employee of the school district. School officials will notify the parent(s) or guardian(s) of all students involved in a bullying incident and the remedial action taken, to the extent permitted by law, based on a confirmed report.
Signature of Parent.
Draw your signature into the box below.

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Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Form for Reporting Alleged Bullying Incidents

Form for Reporting Alleged Bullying Incidents

Student(s) Initiating Bullying/Harassment

Student(s) Being Targeted Bullied