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
First Alleged Offender Information
Second Alleged Offender Information (if applicable)
Third Alleged Offender Information (if applicable)
On what date(s) did the incident happen?
Where did the incident happen (select all that apply)?





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








Was the student victim absent from school as a result of the incident?
About person reporting this incident