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This form is intended for parents, teachers, and students to report any incident of harassment, intimidation, or bullying. All Atlantic City School District staff members are required to enter their name and fill out ALL boxes. Everyone else can remain anonymous. However, if you want to be contacted for follow-up you will need to enter your contact information.

PLEASE NOTE: This form is being submitted to an electronic queue for investigation. There is no guarantee that it will be read immediately. In the event that a student is in imminent danger, please contact the school or your local police department immediately.

Date of Incident:
Time of Incident:
Indicate how you learned that a student may have been a victim of harassment, intimidation or bullying:
Target (Victim)
First Name:
Last Name:
Alleged Offender(s)
First Name:
Last Name:
Contact Info

First Name:
Last Name:
Phone Number:
Best time to call:

Please select all that apply.

Where did the incident happen (choose all that apply)?

First Name:
Last Name:
Physical Evidence
If you feel that the incident was in any way motivated by any of the following please indicate by checking where appropriate
Document Upload
Optional: Please attach any images or videos relevant to this incident. If you wish to select multiple files for upload, click "Choose Files" and then hold the Ctrl button on your keyboard while choosing each file.

Is there any additional relevant information that you would like to provide?
Be sure to enter all known information before submitting.