Harassment-Bullying Reporting Form

Lower Moreland Township School District

Harassment/Bullying Reporting Form

It is the policy of Lower Moreland Township School District to maintain a learning and working environment that is free from harassment/intimidation/bullying.

Please complete this form with as much information as possible.

Date: _________________ Report filed by: _________________________________

Name(s) and grade(s) of alleged student involved in harassing/bullying:

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Name(s) and grade(s) of alleged student victim(s):

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Witnesses (adults and/or students) who might have observed the incident:

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List the events that have occurred. Attach an additional sheet if necessary.

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How long has this been happening? Please be specific. ____________________________________________

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When and where is it happening? (Examples at home, in class, in the hallway, during lunch, in the locker room, between classes, in the bathroom, in the cafeteria). Please be specific.

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What did you do when it happened? Please list all of the ways that you responded.

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Whom have you reported this to ? (check all that apply): _____ Nobody _____ Parent/guardian(s)

_____ Friend(s) _____ Counselor _____ Bus Driver _____ Administrator

_____ Teacher Name:_______________ _____Other Name: ________________

What would you like for an adult to do to help you? (Example: listen to me, talk to the other student(s), watch out for similar behavior, tell an administrator)

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Student Signature: _________________________________

Signature of Staff Member Receiving Form: __________________________________

For Office Use Only

Administrative Follow Up:

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