CAMPUS:

BULLYING COMPLAINT / REPORT FORM

DATE: NAME: ID# GRADE:

Please answer the following questions:

Who is being bullied? Name: If more than one person is being bullied, please identify all victims: Grade:

Who is the bully? If more than one person, please list all bullies:

When and where has the bullying occurred?

Were there any witnesses? If YES, list any and all witnesses:

YES

NO

Describe what has happened in detail:

CONTINUE ON BACK

Is this the first time you have been bullied? If NO, how many times has it happened before? Is the bully the same person? Explain with details: YES

YES When? NO

NO Where?

CONTINUE ON BACK Please include any other information you feel would be helpful or important for the school to know below:

I verify that all information given above is true and complete. I understand any intentional misstatement, false statement or allegation, will subject me to appropriate consequences. Print Name: Signature:

Office Use Only:

School Official receiving complaint: School Official conducting follow-up: Results and Actions Taken:

Date Investigation began: Date Investigation concluded:

Note: Attach any documentation/information from student or staff and place in student discipline file folder.