Report Bullying

Bullying Report Form

Instructions:

Bullying is serious and will not be tolerated. This is a form to report alleged bullying that occurred on school property, at a school-sponsored event off school property, on a school bus, on the way to and/or from school, or on an electronic device.

If you are a student, parent/guardian, close relative, teacher, or other staff member and wish to report an incident of alleged bullying, complete the entire form and respond only to questions that you feel comfortable answering and are able to accurately answer.

You may choose to include your name on the form or you may submit it anonymously. Please note that the district’s ability to investigate an anonymous complaint may be limited and the district prohibits retaliation against anyone who files a bullying report.

You can choose to fill-out and submit this form online or print the form out and return it to your site principal or the district office. Please contact the school or district office if you require additional information or assistance.

Open the Bullying Report Form (PDF), fill it out online and print

Reporter Information

Incident Information

If you don't know names, please describe him/her/them​
If you don't know the alleged bully's name, please describe him/her/them​​​
first and last name and grade, if known. If you don't know the victim's name, please describe him/her/them​​
(i.e., letters, texts, photos, etc.)​​​​
Max file size: 10 MB
(i.e., letters, texts, photos, etc.)​​​​​
Max file size: 10 MB
(i.e., letters, texts, photos, etc.)​​​​
Max file size: 10 MB

LeyVa Middle School

  • 1865 Monrovia Drive
  • |
  • San Jose, CA 95122-1505
  • |
  • Phone: 408-270-4992
  • |
  • Fax: 408-270-5462
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