Cedars International Academy Schools Bullying/Cyber-Bullying Report Form

In accordance with "David's Law", please use this form to report bullying, cyber-bullying, and/or harassment. Required fields are marked with an asterisk *

Please note that incident/cyber-bullying reports are not read immediately after submission but are generally read within 24-hours on regular school days and within 48-hours on the weekend. If you or someone you know is in crisis or in danger, please do not leave a bullying report. Instead, please call 911. This will ensure that someone will be able to respond immediately to the emergency situation.

You have the option to enter your contact information if you wish to be contacted regarding the incident/situation.

General Information

Your Name (Optional, but helpful): Please understand that, without providing your contact information, it may be difficult to pursue this report and to inform you of the status of the situation. If you would like to receive an email update on the status of the situation that you have reported, you will need to leave your contact information (email) in this section.

Answer required for "Your Name (Optional, but helpful): Please understand that, without providing your contact information, it may be difficult to pursue this report and to inform you of the status of the situation. If you would like to receive an email update on the status of the situation that you have reported, you will need to leave your contact information (email) in this section."

I am a:*

Answer required for "I am a:"

Victim

Family Member/Guardian

Student Witness

Other:

Please describe what happened. Include information about the offender (bully), victim, and any witnesses/bystanders.

Alleged Offender's Name*

Answer required for "Alleged Offender's Name"

Alleged Victim's Name*

Answer required for "Alleged Victim's Name"

Any Witnesses/Bystanders (Separate each name with a semicolon ;)*

Answer required for "Any Witnesses/Bystanders (Separate each name with a semicolon ;)"

Which of the following best describes what happened? (Choose all that apply)*

Answer required for "Which of the following best describes what happened? (Choose all that apply)"

Physical Contact

Teasing

Intimidation

Social Exclusion

Cyber-Bullying/Online Harrassment

Which of the following statements best describes why you believe the behavior happened?

Answer required for "Which of the following statements best describes why you believe the behavior happened?"

Please describe the incident in as much detail as possible.*

Answer required for "Please describe the incident in as much detail as possible."

Location of the incident:*

Answer required for "Location of the incident:"

Cedars International Academy - Elementary

Cedars International Academy - Middle School

Cedars International Next Generation High School

Off Campus

Other:

Date of the incident:*

Answer required for "Date of the incident:"

Time of the incident:*

Answer required for "Time of the incident:"

Did anyone try to stop the behavior? If yes, please indicate who and what steps were taken.*

Answer required for "Did anyone try to stop the behavior? If yes, please indicate who and what steps were taken."

How do you think this situation/behavior can best be resolved?*

Answer required for "How do you think this situation/behavior can best be resolved?"

Have you told anyone else about this incident? Answering this question will allow us to coordinate a response with other agencies/individuals.

Answer required for "Have you told anyone else about this incident? Answering this question will allow us to coordinate a response with other agencies/individuals."

Is there any other information you can provide to help resolve this situation/behavior?

Answer required for "Is there any other information you can provide to help resolve this situation/behavior?"

Please share any files (pictures, screenshots, etc.) relevant to this incident.

Answer required for "Please share any files (pictures, screenshots, etc.) relevant to this incident."

Choose a file or drag it here.

Please fix the highlighted areas below before submitting.

Cedars International Academy Schools Bullying/Cyber-Bullying Report Form