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Bullying, harassment or intimidation is serious and will not be tolerated in the Cole County R-1 School District. This is a form to report alleged bullying, harassment, or intimidation that occurred on school property, at a school-sponsored activity or event off of school property, on a school bus, or on the way to and/or from school in the current school year. If you are a student victim, the parent/guardian of a student victim, a close adult relative of a student victim, or a school staff member, and wish to report an incident of alleged bullying, harassment or intimidation, please contact the district’s Administration immediately. If you are uncomfortable with contacting the Administration, you may complete this online form. Once complete, the results of this form will automatically be sent to the principal at the student victim’s school.

The results of this form will be monitored between the hours of 7 a.m. to 5 p.m. during the school year.  Any reports submitted outside of these hours, or during holidays, will be investigated during the following normally scheduled school day.  Please do not use this system for issues requiring immediate assistance. If this is an emergency requiring immediate assistance, please call 911. Contact the school directly for additional information or assistance during posted office hours.

* Indicates required response to a question

* CURRENT DATE (mm/dd/yyyy)  

* NAME OF PERSON REPORTING If you prefer to remain anonymous, type anonymous.   

YOUR CONTACT INFORMATION - EMAIL ADDRESS 

YOUR CONTACT INFORMATION - PHONE NUMBER 

* DATE INCIDENT OCCURRED (mm/dd/yyyy)  

* APPROXIMATE TIME INCIDENT OCCURRED  

* PEOPLE INVOLVED IN THE INCIDENT Please include the first, last name of the victim(s) and the reported bully(ies). 

* STATE THE NATURE OF YOUR REPORT. Please describe the action(s)/incident(s) you believe may be in violation of the District's anti-bullying policy as clearly as possible, including such things as what physical force or contact, if any, was used and any verbal statements that were made (i.e. threats, requests, demands, etc.). Definitions of 'bullying', 'hazing', and 'cyberbullying' may be found under District Policy. Please provide as many specifics as possible.

DESCRIBE ANY ATTEMPTS YOU MADE TO RESOLVE THE INCIDENT Please note relevant dates, times and places. Please provide as many specifics as possible.

* DID ANYONE ELSE WITNESS THIS INCIDENT If yes, please include both first and last names. If you prefer the witnesses remain anonymous, type "anonymous". If no other witnesses were present, type "none."

WERE THE BULLYING ACTIONS VERBAL OR WRITTEN?

IF WRITTEN, WERE THE ACTIONS CYBERBULLYING If yes, what social media platform source was used? (i.e. Snapchat; Facebook; Twitter; etc)

* ARE YOU AWARE OF ANY PREVIOUS INCIDENTS? Describe any previous incidents and include first and last name of witnesses, dates and times. If you prefer the witnesses remain anonymous, type "anonymous." If no previous incidents, type "none." Please provide as many specifics as possible.

DO YOU HAVE ANY SUGGESTIONS ON HOW TO RESOLVE THIS ISSUE

Thank you for completing this Bullying Report Form. The district will review your information and work towards addressing this incident as quickly as possible.