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Livonia Discrimination, Harassment and Bullying Report Form

All information provided on this form will be confidential. Names of victims and other students involved will not be shared.

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* 1. Did the harassment and/or discrimination INTERFERE with the victims performance in school, educational opportunities or benefits

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* 2. Did the harassment and/or discrimination cause the victim to FEAR for his or her physical safety

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* 3. Offender(s) include:

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* 4. Grade of Victim:

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* 5. Date of incident

Date

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* 6. Where did the incident happen?

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* 7. Did the incident include any of the following (choose all that apply):

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* 8. Was the victim targeted for any of the following areas? (Choose all that apply)

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* 9. Explain the incident in detail:

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