Bullying Report Form

Polk County Public Schools
Online Harassment Or Bullying Reporting Form

Directions: Reports of Bullying or Harassment that effect the learning environment or threaten student safety are serious allegations. Upon submission of this form, the Principal at the student’s school will be notified. Every reported act of bullying or harassment will be investigated and parents will be informed.

Anyone can make a report. All school employees are required to report alleged violations. This form can be completed anonymously by omitting the "Name of Person Reporting the Incident" field.

Contact the school for additional information or assistance at any time.

Victim Information

Name

Student #

Age

Grade:

School:

First Alleged Offender Information

Name

Age

Grade

School

He/she is a student

Second Alleged Offender Information (if applicable)

Name

Age

Grade

School

He/she is a student

Third Alleged Offender Information (if applicable)

Name

Age

Grade

School

He/she is a student

On what date(s) did the incident happen?

First

Second

Third

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

On school property
At a school-sponsored activity off school property
At the bus stop
On a school bus
On the way to/from school
On the Computer

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

Teasing/making fun of
Threat of harm
Stalking/Staring, following, intimidating, or trying to scare
Taking things or breaking others property
Cyber bullying/Posting hurtful or embarrassing things online or social media
Excluding/Being left out
Name Calling
Fighting/hitting/touching
Humiliation/embarrassment

What did the alleged offender(s) say or do?

Did a physical injury result from this incident?

Yes, but it did not required medical attention

Yes, and it required medical attention

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

Yes

Is there any additional information you would like to provide?

About person reporting this incident

Name

Telephone

E-Mail

Select from the choices below to best describe yourself:

Student

Parent/Guardian

Close relative/Other

Report Submission Date