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Care Assessment & Bullying

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Handle With Care

Bullying/Harassment Form — High School

12 Questions

1) Date of Complaint:

2) Name of complainant:

3) Are you filling out this form for yourself or someone else?

(please identify the individual if you are submitting on behalf of someone else)

4) Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)?

5) Date and place of incident or incident(s):

6) Names of any witnesses (if any):

7) Nature of discrimination, harassment, or bullying alleged (Check all that apply)

8) If Other: (optional)

9) In the space below, please describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied. Please be as specific as possible and attach additi

10) I agree that all of the information on this form is accurate and true to the best of my knowledge. Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

11) Date of Signature

12) Upload any additional forms/information here (optional)

Max 10 files | 200 MB limit

Bullying/Harassment Reporting

Handle With Care — High School

9 Questions

1) Student's Name

2) Student's Grade

3) Today's Date

4) Incident Date

5) Incident Details

Please provide any necessary information. Feel free to keep this as general as you feel appropriate. Example: my child had a difficult morning at home.

6) Would you like the building counselor or principal to reach out to you to discuss further?

Yes

7) Your Name & Relationship to the Student

8) Your Email

9) Your Phone Number

Maquoketa Community School District

Care Assessment & Bullying

Handle With Care

Bullying/Harassment Form — High School

Bullying/Harassment Reporting

Handle With Care — High School