• Section 10.66.F.1 - Bullying, Harassment or

    Intimidation Reporting Form

    Dysart Unified School District
    15802 North Parkview Place, Surprise, AZ 85374


    This form is to be confidentially maintained in accordance with the Family  Educational Rights and Privacy Act, 20 U.S.C.§1232g.

    Directions: Bullying, harassment or intimidation is not acceptable. Please complete this form to report alleged bullying, harassment, or intimidation. Contact the school for additional information or assistance at any time.

  • Date captured on form submission

    Add

    Add
  • ** For Office Use Only **

  • Rights/Protections/Services supplied to victim - Date: ________

  • Admin. Signature: ___________________________

  • Admin. Signature: ___________________________

  • Admin. Signature: ___________________________

  • Investigation results provided to victim -              Date: ________

  • Admin. Signature: ___________________________

  • Reference: Section 10.66, Form 10.66.F.1