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First Name
Last Name
Email Address:
Phone Number:
Enter when this incident happened:
Select the school:
Select the location of the incident:
Enter more information about the location of the incident.
Select your role:
Enter any other information about how you were involved or how you know of this incident:
Enter type of harassment, intimidation, bullying, or harm:
Enter type of harassment, intimidation, bullying, or harm:

Types of Harassment, Intimidation 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 is 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

Select the cause of harassment, initimidation, bullying, or harm:
Select the method of harassment, intimidation, bullying or harm:
Enter the victim's age and/or grade:
Enter the name of the victim being harassed, intimidated bullied or harmed:
Enter the offender's age and/or grade:
Select the role of the offender that was harassing, intimidating, bullying, or causing harm:
Enter the name of the bully / bullies:
Enter a description of the incident:
By submitting this form you acknowledge that the information entered is complete, true, and accurate. Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.
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