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REPORT FORM FOR HAZING AND BULLYING (Policy: JFCF-E)

Please review the definition of bullying in the document below to determine whether a form should be completed. Our Hazing and Bullying Policies are also below.

Fairfield City Schools

4641 Bach Lane

Fairfield, Ohio 45014-3095

(Phone) 513-829-6300 (Fax) 513-829-0148

What is Bullying?

When someone says something unintentionally hurtful and they

do it only once...

That is Not Nice.

When someone says or does something intentionally hurtful and they

do it once...

That is Mean.

When someone or a group have a disagreement and everyone is

upset...

That is Conflict.

When someone says or does something intentionally hurtful and they keep doing it, over a period of time, even when you tell them to stop or show them you are upset...

That is Bullying.

Please complete the form below if, after reading the above, is necessary. Required fields are marked with an asterisk *

Click the links below to review our Hazing and Bullying policies.

Hazing and Bullying (Harassment, Intimidation and Dating Violence (Policy JFCF)

Hazing and Bullying Response Procedure (Policy JFCF-R)

Complainant:*

Answer required for "Complainant:"

School

Answer required for "School"

Home Address, Work Address, Home Phone, Work Phone:*

Answer required for "Home Address, Work Address, Home Phone, Work Phone:"

Who is the target of the alleged harassment, intimidation, and/or bullying:

Answer required for "Who is the target of the alleged harassment, intimidation, and/or bullying:"

Name of person(s) involved in the alleged hazing or bullying behavior:*

Answer required for "Name of person(s) involved in the alleged hazing or bullying behavior:"

Date of alleged incident(s):*

Answer required for "Date of alleged incident(s):"

Number of times that the alleged conduct has occurred:*

Answer required for "Number of times that the alleged conduct has occurred:"

Location(s) where the alleged conduct has occurred:

Answer required for "Location(s) where the alleged conduct has occurred:"

Describe the alleged incident as clearly as possible, including such things as what force, if any, was used; any verbal statements (i.e. threats, requests, demands, etc.); what if any physical contact was involved. *

Answer required for "Describe the alleged incident as clearly as possible, including such things as what force, if any, was used; any verbal statements (i.e. threats, requests, demands, etc.); what if any physical contact was involved. "

Attach additional pages as necessary

Answer required for "Attach additional pages as necessary"

Choose a file or drag it here.

List any witnesses who were present:*

Answer required for "List any witnesses who were present:"

This complaint is based upon my honest belief that the person(s) listed above has hazed or bullied me or another person. I hereby certify that the information I have provided in this complaint is true, correct and complete to the best of my knowledge.

Complainant (Your typewritten name will serve as your signature):

Answer required for "Complainant (Your typewritten name will serve as your signature):"

Date:

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Received by:

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Date:

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Fairfield City School District, Fairfield, Ohio

Confirmation Email

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