Bullying/Harassment Incident(s) Report

This form should be used to report a possible incident of bullying as defined in the FAMU Developmental Research School student code of conduct prohibiting bullying and harassment. Bullying (intimidating behavior) involves systematic and chronic infliction of physical hurt or psychological distress on one or more students or employees. Harassment according to school policy is threatening, insulting, or dehumanizing gestures, use of data, telecommunications facilities (wireless phones, text message), or computer software or technology (email, social networking sites, blogs, web pages), or written, verbal or physical conduct directed against a student or employee.

This form can be filled out by any person concerned about bullying or harassment and may be submitted anonymously. If you fear a person is in IMMEDIATE danger, please contact a trusted individual right away!

Name of Person being mistreated
Name of Person accused of bullying/harassment
Dates of incident
Where did the incident happen?
Check the statement(s) that best describe what happened.
Check all that apply.
Taunting and Insults
Cyber Bullying
Social Isolation/Exclusion
Verbal Intimidation
Physical Intimidation
Physical Violence
Public Humiliation
Name Calling
Mean Comments
Access Denied
What did the alleged offender(s) say or do?
Was the incident related to the alleged victimized person's race, gender, or disability? No
Have you reported this incident to anyone before? No
Please list your concerns:
Please list your needs:
  By submitting this form, you are verifying that your statements are true and exact to the best of your knowledge.
Check if you Agree
optional leave blank if you would like this report submitted Anonymously.
First Name Optional
Last Name Optional


Thank you. This report will be followed up in a prompt manner.