BULLYING INCIDENT REPORT FORM

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If you have been the target of bullying or have witnessed the bullying of a Smithville student, complete this form; it will automatically submit it to Mr. Chris Heslinga. Complaints against building principals should be submitted to the Superintendent. Complaints against the Superintendent should be submitted to the Board of Education. Reports of bullying will be investigated and disciplinary action will be taken as warranted.

Students have the right to complete this form anonymously. However, it will be easier for the district to investigate this matter if as much information as possible is provided. Submission of a good faith complaint or report of bullying or harassment will not affect the complainant or reporter’s future employment, grades, learning, or working environment. A complainant that knowingly falsely accuses someone will be subject to disciplinary action.

Name:

Phone Number:

Please select one of the following. You are a: *

Student

Volunteer

Employee

Parent

Other:

Date(s) of alleged bullying: *

Name of student(s) subjected to bullying: *

Person(s) alleged to have committed the bullying or harassment: *

Summarize the incident(s) or occurrence(s) of bullying as accurately as possible. *

Names of Witnesses: *

Have you reported this to anyone else? *

Yes

Other:

If you answered "yes" to the question above, to whom have you reported this incident?

Submit

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