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Harassment, Intimidation, Hazing, and Bullying Report


Reporter's Information

Name of Person Reporting the Incidentrequired
First Name
Last Name
Email Addressrequired
Phone Number
Zip code

Incident Information

When did this incident happen?required
If the incident has happened multiple times, please select the most recent date. (Must contain a date in M/D/YYYY format)
Building Location of Incidentrequired
Location of Incident within the School Buildingrequired
More information
Your Role:required
Please enter any other information about how you were involved or how you know of this incident.required

Types of Harassment, Intimidation, Hazing, and Bullying

Physical involves hurting a person’s body or possessions. Physical includes:

  • Hitting/kicking/pinching

  • Spitting

  • Tripping/pushing

  • Taking or breaking someone’s things

  • Making mean or rude hand gestures

Verbal means saying or writing mean things. Verbal includes:

  • Teasing

  • Name-calling

  • Inappropriate sexual comments

  • Taunting

  • Threatening to cause harm

Social, sometimes referred to as relational, involves hurting someone’s reputation or relationships. Social includes:

  • Leaving someone out on purpose

  • Telling other children not to be friends with someone

  • Spreading rumors about someone

  • Embarrassing someone in public

Cyberbullying is bullying that takes place using electronic technology. Examples of cyberbullying include:

  • Mean text messages or emails

  • Rumors sent by email or posted on social networking sites

  • Embarrassing pictures, videos, websites, or fake profiles


More information at


Type of harassment, intimidation, hazing, bullying, or harm:Please select up to 4 choices
Please select up to 4 choices
Cause of harassment, intimidation, hazing, bullying, or harm:required
Method of harassment, intimidation, hazing, bullying, or harm:required
Name of Victimrequired
First Name
Last Name
What is the victim's age/or grade?required
Name of Offender(if known)
First Name
Last Name
(if known)
What is the offender's age/or grade?
(if known)
Description of the Incidentrequired
Please give as much information as you can about the incident, including witnesses & exact details.