Harassment, Intimidation & Bullying Reporting Form
Incidents of harassment, intimidation or bullying are serious offenses and will not be tolerated at Sterling High School. This form is to be used to report alleged harassment, intimidation and/or bullying that occurred on school property, at a school sponsored activity or at an event off school property in the current school year. Please completely the form below and submit.
Person Reporting * (Required) Parent/Guardian Student Staff Member Visitor Friend Relative Other
Name of Reporter (Optional)
Email Address (Required)
Phone Number (Optional)
Do you wish to remain anonymous? * (Required) Yes No
Name of Alleged Victim(s) * (Required)
Name of Alleged Offender(s) * (Required)
Date of Incident * (Required)
Time of Incident * (Required)
Location * (Required) Classroom Hallway Cafeteria Playground Bathroom On the way to/from school Off School Property Via the Internet Via a Cell Phone Other
Describe the nature of the alleged harassment, intimidation or bullying. Include names of people involved, what occurred and what each person said and did. Include specific words used. * (Required)
How did you learn of the incident? * (Required)
Why do you believe the incident occurred? * (Required)
Did a physical and/or emotional injury occur from the incident? If yes, please describe. * (Required)
Was the alleged victim absent from school as a result of the incident? If yes, please indicate the number of days and specific reason for the absence. * (Required)
List the names of any witnesses or anyone that may have relevant information. Please indicate the relationship of the witness to the alleged victim. * (Required)
I believe the discrimination was based on: * (Required) Race Color Religion Ancestry National Origin Gender Sexual Orientation Gender Identity & Expression Mental, Physical or Sensory Disability Other
Please provide any other pertinent information that will assist in the investigation of this report. (Optional)