Online Bullying/Incident Reporting Form
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1.
School where incident occurred:
*
--Please Select--
Barbara Webster
Bedell
Blanchard
Glen City
Grace Thille
Isbell Middle School
McKevett
Renaissance High School
Santa Paula High School
Off Campus
2.
Location where the incident occurred (optional):
--None--
Lunch Area
Classroom
Restroom
Locker Room
Playground
Bus
Off Campus
3.
Name (optional):
4.
Phone (optional):
5.
Email (optional):
6.
Select which applies to you (optional):
--None--
Student
Parent/Guardian
School Staff
Community Member
Other
7.
Name(s)/Description(s) of alleged offenders (optional):
8.
Please describe the incident. Please include as many details as possible (optional):
9.
Please check all categories that apply to the incident:
*
Select at least 1.
Name Calling
Threat
Cyberbullying
Social Exclusion
Intimidation
Physical Violence
Humiliation
Unwanted Touching
Hazing
Other, please specify
By completing this form, you are verifying that your statements are true and accurate to the best of your knowledge.