This form is to be confidentially maintained in accordance with the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g.


Directions: Harassment and bullying are serious and will not be tolerated. If you are a student, the parent/guardian of a student, a volunteer or visitor, and wish to report an incident of alleged harassment and/or bullying, complete and submit this form. Upon submission the Principal at the student’s school will be notified. All school employees are required to report alleged violations. Contact the school for additional information or assistance at any time. This form can be completed anonymously by omitting the "Name of Person Reporting the Incident" field.

Every reported act of bullying or harassment will be investigated, and parents will be informed.

For additional information about the requirements of a field, hover the mouse cursor over the symbol next to the field.

On what date(s) did the incident happen?

Where did the incident happen (choose all that apply)?

Select the statement(s) that best describes what happened (choose all that apply):

Did a physical injury result from this incident?

Was the student victim absent from school as a result of the incident?

Select from the choices below to best describe yourself:

Report submission date:

Submit Report?

Are you ready to submit this report?

Polk County Schools Bullying Incident Report