NTxCA Potential Bullying Report Form

NTxCA Potential Bullying Report Form

Note to Person Reporting: This form will be confidentially maintained in accordance with the Family Educational rights and Privacy Act ("FERPA"), and generally will not be shared with anyone except those working to investigate or respond to the report. You ARE NOT required to provide your name when completing this form.

Bullying/Harassment Report Form

11 questions

1) Campus

2) Name of Person Completing this Report: optional

3) Alleged Target Student's Name - student being bullied/harassed:

4) Alleged Perpetrator's Name(s) - student(s) doing the bullying/harassing. Please list all:

5) Names of Witness(es) to Alleged Conduct:

6) Date & Time of Incident

Date & Time

7) Location of Incident:

8) Description of Incident(s) or Event(s):

9) Was incident ever reported to anyone else?

10) If so, who? What was done? optional

11) Other information including prior information or threats: optional

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NTxCA Potential Bullying Report Form

Bullying/Harassment Report Form