CLEARFIELD AREA MIDDLE SCHOOL
 BULLYING/HARASSMENT FORM

ANY FALSE REPORTS WILL RESULT IN DISCIPLINARY ACTION EITHER BY THE SCHOOL AND/OR POSSIBLY THE SCHOOL RESOURCE OFFICER

Student filing complaint:
 
Grade:
 
Homeroom Teacher:
 
Who has bullied you:
 
What grade is this person in:
 
What date did this incident take place:
 
What time did this incident take place:
 
How long has this been going on with you and this person:
 
Check all that this person has done to you:
 
Witnesses to this incident:
 
Witnesses to other incidents:
 
Where does it occur:
 
What time of the day(class period, in-between classes, etc.):
 
Who have you told about this incident:
 
Is there anything else you would like to add to this report: