Bullying Harassment Report

Bullying and Harassment Policy

Complete this form to report a possible incident of bullying/harassment as defined in Blossom Montessori School for the Deaf’s Policy against Bullying and Harassment. Once you complete the form below, turn in the form to Blossom’s Director so she can sign the document confirming it has been received, and a copy will be provided to you for your records if you provide a name and an email address. The same consequences that apply if engaging in bullying or harassment also apply to students and adults who wrongfully and intentionally accuse another as a means of bullying or harassment.

Person filling out report (check one): *

*Please note you do have the right to remain anonymous if you chose. If you do leave your name and email address, we can send you a copy of the report.

Name of Person filling out the report:

Email Address

Name(s) of Student / Staff / Adult / Other involved in the Incident: *

Location of Incident (choose one): *

Incident Type (check one): *

Bullying

Harassment

Other

Details of Incident: *

Please describe what happened (Be specific – include date, time,specific location, grade level of the victim(s) and accused and any person(s) involved) and if known, whether the victim or the accused is an ESE student. If this report is regarding an adult, please specify who and include the above details.

If you are human, leave this field blank.

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