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

I am a:*

Answer Required

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

Alleged Victim's Name*

Answer Required

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

Answer Required

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

Answer Required

Physical Contact

Teasing

Intimidation

Social Exclusion

Cyber-Bullying/Online Harrassment

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

Answer Required

Location of the incident:*

Answer Required

Cedars International Academy - Elementary

Cedars International Academy - Middle School

Cedars International Next Generation High School

Off Campus

Other:

Date of the incident:*

Answer Required

Time of the incident:*

Answer Required

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

Answer Required

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

Answer Required

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

Answer Required

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

Answer Required

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

Answer Required

Choose a file or drag it here.

Please fix the highlighted areas below before submitting.

Cedars International Academy Schools Bullying/Cyber-Bullying Report Form