Reporting Form

Full Name (Optional)

Address (Optional)

Phone Number (Optional)

Email Address (Optional)

You are a:
Student
Parent/Guardian
Other, Friend or Relative
Date of incident

Format: dd.mm.yyyy

Student involved in BHDR (Bullying Harasment Discrimination Report)
Grade of student involved in BHDR
Age of student involved in BHDR
School that student attends
Morrisville-Eaton Middle/High School
Edward R. Andrews Elementary
Other - Please use comment

Place of Incident:
Bus
Cafeteria
Hallways
At Locker
In locker room
Playground
In Class - Please provide class in comment
School function (dance, club, athletic game)
School function off grounds (field trip, etc)
By Phone (Call or Text)
Internet
Other - Please use comment

Check the box(s) that describe the BHDR incident
Single bullying incident (happened only one time)
Multiple bullying incidents (happened more than once)
Fear of intimidation but not spoken threat or physical contact
Spoken threat but no physical contact
Spoken threat and physical contact
Weapon involved - Please explain in comment
Other - Please use comment
Name of Bully or Bullies

Please Explain Incident In  Detail

Please provide the names of any witnesses

Witness Grade: (Optional)
Witness Age (Optional)

By filling out a report through this system you are asking the Dignity Act Coordinator, Ms. Dushko in the elementary school or Mr. Brewer in the middle/high school to begin an investigation.

Agree