H1 Bullying Form

H1 Harassment, Intimidation, and Bullying Incident Report Form

Please fill out on your device, then download and print the PDF to turn in.
This form is used to report conduct which may violate Policy 4103, Harassment, Intimidation, and Bullying. Form H-1 must be completed by the complainant or school personnel.
Todays Date

MonthDayYear
Date
Case No
Date Of Incident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Time

Hour Minutes

AM/PM Option
Location Of Incident*
Please Be Specific
Name Of Person Allegedly Harassed*
First and Last Name
School*
School Of Person Allegedly Harassed
Sex*

MaleFemale
Grade*
Grade Of Person Allegedly Being Harassed
Age*
Age Of Person Allegedly Being Harassed
Name Of Person Alleged Harasser*
School (If Known)
School Of Alleged Harasser
Sex (If Known)

MaleFemale
Grade (If Known)
Grade Of Alleged Harasser
Age (If Known)
Age Of Alleged Harasser
Name Of Person Completing This Form If Different From Above
Please Select*

StudentTeacherOther School StaffAdministratorParentOther
Description Of Incident*
Please Be Specific
Names of Witnesses, If Any
First and Last Names Separated By A Comma
Disciplinary action may be taken for false reporting.
Should be Empty: