MHS - Report of suspected harassment & bullying

Please complete the form below. Required fields marked with an asterisk *

Name of Person Completing Report: (student reports may be anonymous)*

Answer Required

Name(s) of alleged victim(s): *

Answer Required

Relationship to victim

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Self

Parent/Guardian

Teacher

Peer

Other:

Complaint Filed Against:*

Answer Required

Date of Incident(s): *

Answer Required

Location:*

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Time:*

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Specify your complaint by stating the problem as you see it. Describe the incident, participants, background to the incident, and any attempts you have made to resolve the problem. Please note relevant dates, times and places. *

Answer Required

Indicate if there are witnesses who can provide more information regarding your complaint. If the witnesses are not school district staff or students, please provide contact information. (Name, Address, Telephone Number)

Answer Required

Who did the bullying? (Name and Grade)*

Answer Required

If “yes”, please describe the behavior of concern, the approximate dates and the location:

Answer Required

If “Yes”, to whom was it reported?

Answer Required

Does the school have parent/guardian consent to disclose the student’s name in connection with the investigation?*

Answer Required

Yes

I certify that the above information and events are accurately depicted to the best of my knowledge.

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

MHS - Report of suspected harassment & bullying