Name:

Phone Number:

E-mail:

Grade:

Are You:

If you are not the student, what is the name of the student allegedly bullied?

What school do you attend?

Where did the incident happen?

Tell us what happened:

What is the person’s name that did the alleged bullying?

Who else witnessed this incident?

Have you already notified any school staff? Who?

Date and time of incident:
v

Help us understand clearly what form the bullying took in this incident, check all that apply:

If other please specify:

I agree that all the information on this form is accurate and true to the best of my personal knowledge.


Send my email.



An administrator with the Burlington Community School District will attempt to contact you within 1-2 business days of receiving this report.

This report may be filed on-line; it may be printed and delivered to any District School Principal’s Office, or delivered to: Burlington Community Schools, 1429 West Avenue, Burlington, IA 52601.
Board Policy 500.2 Exhibit A