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:
PK
KG
01
02
03
04
05
06
07
08
09
10
11
12
School:
Select School
Other (not in list)
Achievement Academy
Alta Vista Elementary
Alturas Elementary
Auburndale Central Elementary
Auburndale Senior High
Bartow Elementary Academy
Bartow Middle
Bartow Senior High
Bartow Youth Academy
Bella Citta Elementary
Ben Hill Griffin Jr. Elementary
Berkley Accelerated Middle
Berkley Elementary
Bethune Academy
Bill Duncan Opportunity Center
Bok Academy
Bok Academy North
Carlton Palmore Elementary
Chain Of Lakes Collegiate High
Chain Of Lakes Elementary
Citrus Ridge: A Civics Academy
Clarence Boswell Elementary
Cleveland Court Elementary
Combee Academy of Design and Engineering
Compass Middle Charter
Crystal Lake Elementary
Crystal Lake Middle
Cypress Junction Montessori
Dale R. Fair Babson Park Elementary
Daniel Jenkins Acad. of Tech. Middle
Davenport Elementary
Davenport High School
Davenport School of the Arts
Denison Middle
Discovery Academy of Lake Alfred
Discovery High School
Dixieland Elementary
Donald E Woods Opportunity Center
Doris A. Sanders Learning Center
Dr. NE Roberts Elementary
Dundee Elementary Academy
Dundee Ridge Middle Academy
Eagle Lake Elementary
East Area Adult
Eastside Elementary
Eckerd Connects Day Treatment
Edgar L. Padgett Elementary
Elbert Elementary
ESE Countywide
ESE Private School
Floral Avenue Elementary
Fort Meade Middle/Senior High
Frank E. Brigham Academy
Fred G. Garner Elementary
Fresh Start Community School
Frostproof Elementary
Frostproof Middle/Senior High
Garden Grove Elementary
Gause Academy of Leadership
George W. Jenkins Senior High
Gibbons Street Elementary
Gibbons Street Pre-K Center
Griffin Elementary
Haines City Head Start Center
Haines City HS IB
Haines City Senior High
Harrison School for the Arts
Hartridge Academy
Highland City Elementary
Highlands Grove Elementary
Highlands Youth Academy
Hillcrest Elementary
Home Education Setting
Horizons Elementary
Hospital Homebound
International Baccalaureate
Inwood Elementary
James E. Stephens Elementary
James W. Sikes Elementary
Janie Howard Wilson
Jean O'Dell Learning Center
Jere L. Stambaugh Middle
Jesse Keen Elementary
Jewett Middle Academy Magnet
Jewett School of the Arts
John Snively Elementary
Karen M. Siegel Academy
Kathleen Elementary
Kathleen Middle
Kathleen Senior High
Kingsford Elementary
Lake Alfred Elementary
Lake Alfred Polytech Academy
Lake Gibson Middle
Lake Gibson Senior High
Lake Marion Creek Middle
Lake Region High
Lake Shipp Elementary
Lake Wales IB
Lake Wales Senior High
Lakeland Highlands Middle
Lakeland Montessori Middle
Lakeland Montessori School House
Lakeland Senior High
Language and Literacy Academy for Learning
Laurel Elementary
Lawton Chiles Middle Academy
Lena Vista Elementary
Lewis Anna Woodbury Elementary
Lewis Elementary PK-3
Lincoln Avenue Academy
Loughman Oaks Elementary
Magnolia Montessori Academy
Maynard A Traviss Technical Academy
McKay Scholarship
McKeel Academy Central
McKeel Academy of Technology
McLaughlin Middle & Fine Arts Academy
Medulla Elementary
Migrant Home Education
Migrant Not Enrolled
Migrant Title 1 Private
Mulberry Middle
Mulberry Senior High
Navigator Academy of Leadership Davenport
New Beginnings High
New Horizons
North Lakeland Elem. School of Choice
Oscar J. Pope Elementary
PACE Center for Girls
Palmetto Elementary
Philip O'Brien Elementary
Pinewood Elementary
Polk Avenue Elementary
Polk City Elementary
Polk Co. Sheriff's Regional Detention C
Polk County Sheriff's Central Center
Polk Full Time eSchool
Polk GRAD Academy
Polk Halfway House
Polk Pre-Collegiate Academy
Polk State College Collegiate High
Polk Virtual Franchise
Polk Virtual Instruction
Polk Virtual Instruction Program
Private School
PS Lakeland Gateway to College CHS
Purcell Elementary
R. Bruce Wagner Elementary
R. Clem Churchwell Elementary
R.E.A.L. Academy
Ridge Community High
Ridge Technical Academy
Ridge Technical College
Ridge Teen Parent Program
Ridgeview Global Studies Academy
Rochelle School Of The Arts
Roosevelt Academy
Rosabelle W. Blake Academy
Sandhill Elementary
Scott Lake Elementary
Shelley S. Boone Middle
Sleepy Hill Elementary
Sleepy Hill Middle
Socrum Elementary
South McKeel Academy
Southwest Elementary
Southwest Middle
Spessard L Holland Elementary
Spook Hill Elementary
Summerlin Academy
Tenoroc High
Title 1 Private School
Transition School
Traviss Technical College
Union Academy
Valleyview Elementary
Victory Ridge Academy
Wahneta Elementary
Walter Caldwell Elementary
Wendell Watson Elementary
West Area Adult/Community
Westwood Middle
Willow Oak School
Winston Academy of Engineering
Winter Haven Head Start
Winter Haven Senior High
First Alleged Offender Information
Name
Age
Grade
PK
KG
01
02
03
04
05
06
07
08
09
10
11
12
School
Select School
Achievement Academy
Alta Vista Elementary
Alturas Elementary
Auburndale Central Elementary
Auburndale Senior High
Bartow Elementary Academy
Bartow Middle
Bartow Senior High
Bartow Youth Academy
Bella Citta Elementary
Ben Hill Griffin Jr. Elementary
Berkley Accelerated Middle
Berkley Elementary
Bethune Academy
Bill Duncan Opportunity Center
Bok Academy
Bok Academy North
Carlton Palmore Elementary
Chain Of Lakes Collegiate High
Chain Of Lakes Elementary
Citrus Ridge: A Civics Academy
Clarence Boswell Elementary
Cleveland Court Elementary
Combee Academy of Design and Engineering
Compass Middle Charter
Crystal Lake Elementary
Crystal Lake Middle
Cypress Junction Montessori
Dale R. Fair Babson Park Elementary
Daniel Jenkins Acad. of Tech. Middle
Davenport Elementary
Davenport High School
Davenport School of the Arts
Denison Middle
Discovery Academy of Lake Alfred
Discovery High School
Dixieland Elementary
Donald E Woods Opportunity Center
Doris A. Sanders Learning Center
Dr. NE Roberts Elementary
Dundee Elementary Academy
Dundee Ridge Middle Academy
Eagle Lake Elementary
East Area Adult
Eastside Elementary
Eckerd Connects Day Treatment
Edgar L. Padgett Elementary
Elbert Elementary
ESE Countywide
ESE Private School
Floral Avenue Elementary
Fort Meade Middle/Senior High
Frank E. Brigham Academy
Fred G. Garner Elementary
Fresh Start Community School
Frostproof Elementary
Frostproof Middle/Senior High
Garden Grove Elementary
Gause Academy of Leadership
George W. Jenkins Senior High
Gibbons Street Elementary
Gibbons Street Pre-K Center
Griffin Elementary
Haines City Head Start Center
Haines City HS IB
Haines City Senior High
Harrison School for the Arts
Hartridge Academy
Highland City Elementary
Highlands Grove Elementary
Highlands Youth Academy
Hillcrest Elementary
Home Education Setting
Horizons Elementary
Hospital Homebound
International Baccalaureate
Inwood Elementary
James E. Stephens Elementary
James W. Sikes Elementary
Janie Howard Wilson
Jean O'Dell Learning Center
Jere L. Stambaugh Middle
Jesse Keen Elementary
Jewett Middle Academy Magnet
Jewett School of the Arts
John Snively Elementary
Karen M. Siegel Academy
Kathleen Elementary
Kathleen Middle
Kathleen Senior High
Kingsford Elementary
Lake Alfred Elementary
Lake Alfred Polytech Academy
Lake Gibson Middle
Lake Gibson Senior High
Lake Marion Creek Middle
Lake Region High
Lake Shipp Elementary
Lake Wales IB
Lake Wales Senior High
Lakeland Highlands Middle
Lakeland Montessori Middle
Lakeland Montessori School House
Lakeland Senior High
Language and Literacy Academy for Learning
Laurel Elementary
Lawton Chiles Middle Academy
Lena Vista Elementary
Lewis Anna Woodbury Elementary
Lewis Elementary PK-3
Lincoln Avenue Academy
Loughman Oaks Elementary
Magnolia Montessori Academy
Maynard A Traviss Technical Academy
McKay Scholarship
McKeel Academy Central
McKeel Academy of Technology
McLaughlin Middle & Fine Arts Academy
Medulla Elementary
Migrant Home Education
Migrant Not Enrolled
Migrant Title 1 Private
Mulberry Middle
Mulberry Senior High
Navigator Academy of Leadership Davenport
New Beginnings High
New Horizons
North Lakeland Elem. School of Choice
Oscar J. Pope Elementary
PACE Center for Girls
Palmetto Elementary
Philip O'Brien Elementary
Pinewood Elementary
Polk Avenue Elementary
Polk City Elementary
Polk Co. Sheriff's Regional Detention C
Polk County Sheriff's Central Center
Polk Full Time eSchool
Polk GRAD Academy
Polk Halfway House
Polk Pre-Collegiate Academy
Polk State College Collegiate High
Polk Virtual Franchise
Polk Virtual Instruction
Polk Virtual Instruction Program
Private School
PS Lakeland Gateway to College CHS
Purcell Elementary
R. Bruce Wagner Elementary
R. Clem Churchwell Elementary
R.E.A.L. Academy
Ridge Community High
Ridge Technical Academy
Ridge Technical College
Ridge Teen Parent Program
Ridgeview Global Studies Academy
Rochelle School Of The Arts
Roosevelt Academy
Rosabelle W. Blake Academy
Sandhill Elementary
Scott Lake Elementary
Shelley S. Boone Middle
Sleepy Hill Elementary
Sleepy Hill Middle
Socrum Elementary
South McKeel Academy
Southwest Elementary
Southwest Middle
Spessard L Holland Elementary
Spook Hill Elementary
Summerlin Academy
Tenoroc High
Title 1 Private School
Transition School
Traviss Technical College
Union Academy
Valleyview Elementary
Victory Ridge Academy
Wahneta Elementary
Walter Caldwell Elementary
Wendell Watson Elementary
West Area Adult/Community
Westwood Middle
Willow Oak School
Winston Academy of Engineering
Winter Haven Head Start
Winter Haven Senior High
He/she is a student
Second Alleged Offender Information (if applicable)
Name
Age
Grade
PK
KG
01
02
03
04
05
06
07
08
09
10
11
12
School
Select School
Achievement Academy
Alta Vista Elementary
Alturas Elementary
Auburndale Central Elementary
Auburndale Senior High
Bartow Elementary Academy
Bartow Middle
Bartow Senior High
Bartow Youth Academy
Bella Citta Elementary
Ben Hill Griffin Jr. Elementary
Berkley Accelerated Middle
Berkley Elementary
Bethune Academy
Bill Duncan Opportunity Center
Bok Academy
Bok Academy North
Carlton Palmore Elementary
Chain Of Lakes Collegiate High
Chain Of Lakes Elementary
Citrus Ridge: A Civics Academy
Clarence Boswell Elementary
Cleveland Court Elementary
Combee Academy of Design and Engineering
Compass Middle Charter
Crystal Lake Elementary
Crystal Lake Middle
Cypress Junction Montessori
Dale R. Fair Babson Park Elementary
Daniel Jenkins Acad. of Tech. Middle
Davenport Elementary
Davenport High School
Davenport School of the Arts
Denison Middle
Discovery Academy of Lake Alfred
Discovery High School
Dixieland Elementary
Donald E Woods Opportunity Center
Doris A. Sanders Learning Center
Dr. NE Roberts Elementary
Dundee Elementary Academy
Dundee Ridge Middle Academy
Eagle Lake Elementary
East Area Adult
Eastside Elementary
Eckerd Connects Day Treatment
Edgar L. Padgett Elementary
Elbert Elementary
ESE Countywide
ESE Private School
Floral Avenue Elementary
Fort Meade Middle/Senior High
Frank E. Brigham Academy
Fred G. Garner Elementary
Fresh Start Community School
Frostproof Elementary
Frostproof Middle/Senior High
Garden Grove Elementary
Gause Academy of Leadership
George W. Jenkins Senior High
Gibbons Street Elementary
Gibbons Street Pre-K Center
Griffin Elementary
Haines City Head Start Center
Haines City HS IB
Haines City Senior High
Harrison School for the Arts
Hartridge Academy
Highland City Elementary
Highlands Grove Elementary
Highlands Youth Academy
Hillcrest Elementary
Home Education Setting
Horizons Elementary
Hospital Homebound
International Baccalaureate
Inwood Elementary
James E. Stephens Elementary
James W. Sikes Elementary
Janie Howard Wilson
Jean O'Dell Learning Center
Jere L. Stambaugh Middle
Jesse Keen Elementary
Jewett Middle Academy Magnet
Jewett School of the Arts
John Snively Elementary
Karen M. Siegel Academy
Kathleen Elementary
Kathleen Middle
Kathleen Senior High
Kingsford Elementary
Lake Alfred Elementary
Lake Alfred Polytech Academy
Lake Gibson Middle
Lake Gibson Senior High
Lake Marion Creek Middle
Lake Region High
Lake Shipp Elementary
Lake Wales IB
Lake Wales Senior High
Lakeland Highlands Middle
Lakeland Montessori Middle
Lakeland Montessori School House
Lakeland Senior High
Language and Literacy Academy for Learning
Laurel Elementary
Lawton Chiles Middle Academy
Lena Vista Elementary
Lewis Anna Woodbury Elementary
Lewis Elementary PK-3
Lincoln Avenue Academy
Loughman Oaks Elementary
Magnolia Montessori Academy
Maynard A Traviss Technical Academy
McKay Scholarship
McKeel Academy Central
McKeel Academy of Technology
McLaughlin Middle & Fine Arts Academy
Medulla Elementary
Migrant Home Education
Migrant Not Enrolled
Migrant Title 1 Private
Mulberry Middle
Mulberry Senior High
Navigator Academy of Leadership Davenport
New Beginnings High
New Horizons
North Lakeland Elem. School of Choice
Oscar J. Pope Elementary
PACE Center for Girls
Palmetto Elementary
Philip O'Brien Elementary
Pinewood Elementary
Polk Avenue Elementary
Polk City Elementary
Polk Co. Sheriff's Regional Detention C
Polk County Sheriff's Central Center
Polk Full Time eSchool
Polk GRAD Academy
Polk Halfway House
Polk Pre-Collegiate Academy
Polk State College Collegiate High
Polk Virtual Franchise
Polk Virtual Instruction
Polk Virtual Instruction Program
Private School
PS Lakeland Gateway to College CHS
Purcell Elementary
R. Bruce Wagner Elementary
R. Clem Churchwell Elementary
R.E.A.L. Academy
Ridge Community High
Ridge Technical Academy
Ridge Technical College
Ridge Teen Parent Program
Ridgeview Global Studies Academy
Rochelle School Of The Arts
Roosevelt Academy
Rosabelle W. Blake Academy
Sandhill Elementary
Scott Lake Elementary
Shelley S. Boone Middle
Sleepy Hill Elementary
Sleepy Hill Middle
Socrum Elementary
South McKeel Academy
Southwest Elementary
Southwest Middle
Spessard L Holland Elementary
Spook Hill Elementary
Summerlin Academy
Tenoroc High
Title 1 Private School
Transition School
Traviss Technical College
Union Academy
Valleyview Elementary
Victory Ridge Academy
Wahneta Elementary
Walter Caldwell Elementary
Wendell Watson Elementary
West Area Adult/Community
Westwood Middle
Willow Oak School
Winston Academy of Engineering
Winter Haven Head Start
Winter Haven Senior High
He/she is a student
Third Alleged Offender Information (if applicable)
Name
Age
Grade
PK
KG
01
02
03
04
05
06
07
08
09
10
11
12
School
Select School
Achievement Academy
Alta Vista Elementary
Alturas Elementary
Auburndale Central Elementary
Auburndale Senior High
Bartow Elementary Academy
Bartow Middle
Bartow Senior High
Bartow Youth Academy
Bella Citta Elementary
Ben Hill Griffin Jr. Elementary
Berkley Accelerated Middle
Berkley Elementary
Bethune Academy
Bill Duncan Opportunity Center
Bok Academy
Bok Academy North
Carlton Palmore Elementary
Chain Of Lakes Collegiate High
Chain Of Lakes Elementary
Citrus Ridge: A Civics Academy
Clarence Boswell Elementary
Cleveland Court Elementary
Combee Academy of Design and Engineering
Compass Middle Charter
Crystal Lake Elementary
Crystal Lake Middle
Cypress Junction Montessori
Dale R. Fair Babson Park Elementary
Daniel Jenkins Acad. of Tech. Middle
Davenport Elementary
Davenport High School
Davenport School of the Arts
Denison Middle
Discovery Academy of Lake Alfred
Discovery High School
Dixieland Elementary
Donald E Woods Opportunity Center
Doris A. Sanders Learning Center
Dr. NE Roberts Elementary
Dundee Elementary Academy
Dundee Ridge Middle Academy
Eagle Lake Elementary
East Area Adult
Eastside Elementary
Eckerd Connects Day Treatment
Edgar L. Padgett Elementary
Elbert Elementary
ESE Countywide
ESE Private School
Floral Avenue Elementary
Fort Meade Middle/Senior High
Frank E. Brigham Academy
Fred G. Garner Elementary
Fresh Start Community School
Frostproof Elementary
Frostproof Middle/Senior High
Garden Grove Elementary
Gause Academy of Leadership
George W. Jenkins Senior High
Gibbons Street Elementary
Gibbons Street Pre-K Center
Griffin Elementary
Haines City Head Start Center
Haines City HS IB
Haines City Senior High
Harrison School for the Arts
Hartridge Academy
Highland City Elementary
Highlands Grove Elementary
Highlands Youth Academy
Hillcrest Elementary
Home Education Setting
Horizons Elementary
Hospital Homebound
International Baccalaureate
Inwood Elementary
James E. Stephens Elementary
James W. Sikes Elementary
Janie Howard Wilson
Jean O'Dell Learning Center
Jere L. Stambaugh Middle
Jesse Keen Elementary
Jewett Middle Academy Magnet
Jewett School of the Arts
John Snively Elementary
Karen M. Siegel Academy
Kathleen Elementary
Kathleen Middle
Kathleen Senior High
Kingsford Elementary
Lake Alfred Elementary
Lake Alfred Polytech Academy
Lake Gibson Middle
Lake Gibson Senior High
Lake Marion Creek Middle
Lake Region High
Lake Shipp Elementary
Lake Wales IB
Lake Wales Senior High
Lakeland Highlands Middle
Lakeland Montessori Middle
Lakeland Montessori School House
Lakeland Senior High
Language and Literacy Academy for Learning
Laurel Elementary
Lawton Chiles Middle Academy
Lena Vista Elementary
Lewis Anna Woodbury Elementary
Lewis Elementary PK-3
Lincoln Avenue Academy
Loughman Oaks Elementary
Magnolia Montessori Academy
Maynard A Traviss Technical Academy
McKay Scholarship
McKeel Academy Central
McKeel Academy of Technology
McLaughlin Middle & Fine Arts Academy
Medulla Elementary
Migrant Home Education
Migrant Not Enrolled
Migrant Title 1 Private
Mulberry Middle
Mulberry Senior High
Navigator Academy of Leadership Davenport
New Beginnings High
New Horizons
North Lakeland Elem. School of Choice
Oscar J. Pope Elementary
PACE Center for Girls
Palmetto Elementary
Philip O'Brien Elementary
Pinewood Elementary
Polk Avenue Elementary
Polk City Elementary
Polk Co. Sheriff's Regional Detention C
Polk County Sheriff's Central Center
Polk Full Time eSchool
Polk GRAD Academy
Polk Halfway House
Polk Pre-Collegiate Academy
Polk State College Collegiate High
Polk Virtual Franchise
Polk Virtual Instruction
Polk Virtual Instruction Program
Private School
PS Lakeland Gateway to College CHS
Purcell Elementary
R. Bruce Wagner Elementary
R. Clem Churchwell Elementary
R.E.A.L. Academy
Ridge Community High
Ridge Technical Academy
Ridge Technical College
Ridge Teen Parent Program
Ridgeview Global Studies Academy
Rochelle School Of The Arts
Roosevelt Academy
Rosabelle W. Blake Academy
Sandhill Elementary
Scott Lake Elementary
Shelley S. Boone Middle
Sleepy Hill Elementary
Sleepy Hill Middle
Socrum Elementary
South McKeel Academy
Southwest Elementary
Southwest Middle
Spessard L Holland Elementary
Spook Hill Elementary
Summerlin Academy
Tenoroc High
Title 1 Private School
Transition School
Traviss Technical College
Union Academy
Valleyview Elementary
Victory Ridge Academy
Wahneta Elementary
Walter Caldwell Elementary
Wendell Watson Elementary
West Area Adult/Community
Westwood Middle
Willow Oak School
Winston Academy of Engineering
Winter Haven Head Start
Winter Haven Senior High
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?
No
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?
No
Yes
If yes, how many days was the student victim absent from school as a result of the incident?
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
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