ALBERT LEA AREA SCHOOLS

Bullying Report Form

Please submit to main office when complete. Please provide detailed information.
Name of Person Making Report: ___________________________
Date of Report: ___________________
Name(s) and Grade Level(s) of Offender(s): __________________________________
Name(s) and Grade Level(s) of Victim(s): ____________________________________
Name(s) and Grade Level(s) of Witness(es): ____________________________________
Date(s) and Time(s) when bullying or prohibited conduct took place:
________________________________________________________________________
________________________________________________________________________
Location where bullying or prohibited conduct took place:
________________________________________________________________________
________________________________________________________________________
Description of Bullying Incident(s) or Prohibited Conduct:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
TENNESSEN NOTICE: This form is being collected for the purpose of allowing the District to investigate bullying or other prohibited conduct.
You are not legally required to provide any private information on this form. However if you choose to provide this information, the District will
use it to investigate the matter(s) you report. If you do not provide information, the District may be unable to investigate your report. This
information constitutes private educational or personnel data, but may be shared with the following persons or entities: the Districts School
Board, the Superintendent, District staff who have a need to know the information, the Districts legal counsel, law enforcement, the Minnesota
Department of Education, the Minnesota State High School League and other individuals directly or indirectly involved in the matters discussed,
including witnesses. Data may also be shared pursuant to a court order.

For Office Use Only:

Recd: __________
Date

Investigation by ________________________on __________________

Date
Date