Eastern Hancock Schools

1) First Name

2) Last Name

3) Email

4) Phone Number

5) Address (street, city, zip)

6) When did the incident happen?

8) Please add any additional information about the location of the incident:

10) Please enter any other information about how you were involved or how you know of this incident.

13) Please enter as much information as possible about the type of bullying you are reporting.

14) What is the victim's age/or grade?

15) Who was the person being harassed, intimidated, hazed, bullied or harmed? Please include the name(s) of the victim(s) if you know them.

16) What is the offender's age and/or grade?

17) Please enter the names of the bullies if you have them.

18) Please give us as much information as you can about the incident, including any witnesses & what happened.

19) By typing your initials, you agree to the disclaimer below.

By submitting this form you acknowledge that the information entered is complete, true, and accurate. Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.

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