If date and/or time of the incident are unknown, if possible, please give a general timeframe for the incident.
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School *
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Amelia
Clough Pike
Holly Hill
Merwin
Summerside
Willowville
Withamsville-Tobasco
West Clermont Middle School
West Clermont High School
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Location *
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Please enter more information about the location of the incident to assist in identifying where the incident occurred. *
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Your Role *
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Administrator
Bystander
Parent/Caregiver
Staff Member
Teacher
Student
Volunteer
Please enter any other information about how you were involved or how you know of this incident. *
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Type / method of harassment, intimidation, hazing, or bullying *
Required
Please enter as much information as possible about the type / method of harassment, intimidation, hazing, or bullying you are reporting (e.g., electronic communication, written communication, relationship / dating). *
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Cause of harassment, intimidation, hazing, or bullying: *
Required
Name(s) of the person being harassed, intimidated, hazed, or bullied? *
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Victim's Age *
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3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Unknown
Adult
Victim's Grade *
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PK
K
1
2
3
4
5
6
7
8
9
10
11
12
Uknown
Adult
Who was harassing, intimidating, hazing, or bullying? *
Offender(s) Name *
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Offenders Age *
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3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Unknown
Adult
Offender's Grade *
Choose
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
Uknown
Adult
Please provide as much information as possible about the incident, including names of witnesses and exactly what happened. *
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