Bullying/Harassment Report Form

Barrington School District maintains a firm policy prohibiting all forms of bullying. Everyone is
to be treated with respect and dignity. Bullying by any student, teacher, administrator or
other school personnel which creates an intimidating environment will not be tolerated under
any circumstances.

- Only use this form to report issues relating to racism, bullying, cyber-bullying, harassment -

Your name: (optional, but helpful)
Please understand, without providing your contact information it may be difficult to pursue this report.

I am a: Student Guardian/Family Member

My School: (required)

Describe what happened:
Include information on the bully, victim, any witnesses/bystanders; the more detail you provide the better.

Location: Other:

Date and Time this happened:

What sort of help would you like with this issue? (optional)

Have you told anyone else about this incident? Who? (optional)

Additional Information: (optional)

This form is sent to the appropriate school personnel, who will research your report and respond as necessary.