Midwest Surfboard Company

Please use this feature to attach any additional documentation needed for the report.

Reporting Person Information *optional

Student     Parent     Community Member

Name

Telephone   Email

Incident Details

School SiteSelect SchoolSOCS TestingArrow Springs ECCAspen Creek ECCCreekwood ECCPark Lane ECCArrowheadAspen CreekCounty Lane PrimaryCountry Lane IntermediateCreekwoodHighland ParkLeisure ParkLibertyLynn WoodOak CrestRhoadesSpring CreekTimber RidgeVandeverWolf CreekCentennial Middle SchoolChilders Middle SchoolOliver Middle SchoolOneta Ridge Middle SchoolSequoyah Middle SchoolFreshman AcademyHigh School - 12thHigh School - 11thHigh School - 10thBA AcademyBA Virtual SchoolMentoring Healthy Parents  *required

Date  Time

Name of Student Affected  Grade

Name and grade level of student(s) initiating bullying. (if you don't know the student's name(s) describe him/her)

Description of bullying incident(s): where, when, & what happened.

Name(s)of any witnesses and their grade level.

Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)? (yes, no, unsure)

SelectYesNoUnsure

Type of Alleged Harassment

Racial     Sexual     Religious     Other

Is this a repeat offense? Yes      No

Has a complaint relevant to this issue been filed before? Yes      No

Check all spaces below that apply. Inappropriate behaviors include:

Once you have clicked the submit tab, your report will be submitted to the site principal. Reports filed with contact information will receive a response within a reasonable amount of time to allow administrators to investigate the report.

Thank you for assisting our district in our joint effort to stop and prevent bullying.