Davisville Middle School

1) Name: *

Please provide your name

2) Student ID: *

If you are a student, please provide your student ID number.

3) Grade: *

If you are a student, please provide your current grade level

4) School: *

Please provide the name of the school you attend.

5) List the name of the alleged bully, and/pr cyber-bully. If name is not known, provide any other identifiable information: *

6) Relationship between you and the alleged bully, and/or cyber-bully: *

7) Describe the incident: *

8) When and where did it happen? *

9) Where there any witnesses? *

Yes

No

10) If you reported that there were witnesses, then please provide their names below: (optional)

11) Other information, including previous incidents or threats: *

12) Please type your name and today's date below. *

I certify that all statements made in complaint are true and complete. Any intentional false statement of fact will subject me to appropriate discipline.

Davisville Middle School

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