*Choose school 
Choose....Onalaska Elementary/IntermediateOnalaska Junior/Senior High
 

*Name of student target (victim) 

*Date of incident you are reporting 

*Where did the incident happen? Choose all that apply.
      On school property during the school day
      On a school bus on the way to/from school
      On a school bus on the way to/from a school-sponsored activity
      At a school-sponsored activity/event on school property
      At a school-sponsored activity/event OFF school property
      At a bus stop
      Classroom
      Hallway
      Restroom
      Locker room
      Cafeteria
      Parking lot
      Track
      Cyber-bullying  cellphone
      Cyber-bullying computer
      Other place If other, please specify 
          

*Has the appropriate teacher/coach/bus driver been contacted?  Yes      No  

If yes, please provide the name(s) of who you have contacted 
         

*Did you report this to anyone else, such as police, parent, other teacher, sheriff, etc.?  Yes      No  

If yes, please provide the name(s) of who you have contacted 
        

*Name(s) or description if unknown of alleged bully(ies) 
        

*Please select the statement(s) that best describe what happened. Choose all that apply.
      Hitting, kicking, shoving, spitting, hair pulling, or throwing something
      Getting another person to hit or harm the student
      Teasing, name calling, making critical remarks, or threatening, in person or by other means
      Demeaning and make the victim of jokes
      Making rude and/or threatening gestures
      Excluding or rejecting the student
      Intimidating, extorting, or exploiting
      Spreading harmful rumors or gossip
      Cyber-bullying
      Sexual Harassment
      Other if other, please specify 
          

*What did the alleged bully(ies) say or do?
         

*Why did the harassment or intimidation occur?
        

*Were there any witnesses or bystanders?  Yes      No  

If yes, please provide their name/s 
       

*Did physical injury result from the incident?  Yes      No  

Was the target (victim) absent from school as a result of the incident? Yes      No  

Please provide any additional information
        

*Has the target (victim) experienced problems with this particular person before? Yes      No  

If yes, please provide details. 
        

*What action do you believe the school should take with regard to this incident?
        

*If this matter proceeds to a formal hearing, will you appear and testify as to your knowledge of the matter?  Yes      No  

Name of person(s) making this report (optional) 
        

E-mail (optional) 
        

Phone Number (optional) 
        

*required fields