Montgomery County R-II School District
Bullying Incident Report Form
If you have been the target of bullying or have witnessed the bullying of a District student, complete this form and submit to the building Principal. Complaints against building Principals should be submitted to the Board of Education. Reports of bullying will be investigated and disciplinary action will be taken as warranted. This form can be submitted anonymously.
Indicate the appropriate response:
You are a: Student Parent Employee Other
Date(s) of alleged bullying:
Name of student(s) subjected to bullying:
Person(s) alleged to have committed the bullying:
Summarize the incident(s) of bullying as accurate as possible:
Name(s) of witnesses:
Have you reported this incident to anyone? Yes No If Yes, whom?
Students have the right to complete this form anonymously. However, if 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 will not affect your future employment , grades, learning or working environment. A complainant that falsely accuses someone will be subject to disciplinary action.
This section for District use ONLY.
Date received by Principal:
Investigative Action Taken:
Result of Investigation/Action taken:
Signature of Principal: