Case Form: School Bullying & Sexual Violence

Student's Name *

Your Name

(if not the student) and Relationship to Student (such as, “Jane Smith, Mother”)

Email *

Home Phone

Cell Phone

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Your Pronouns

We actively work to address everyone appropriately and acknowledge their identity. Examples of common pronouns are 'she/her/hers,' 'he/him/his,' and 'they/them/theirs.' If you’re comfortable, please share your pronouns:

Type of Incident *

(Please select all that apply)

Describe "Other" Incident *

Why do you think you were targeted? *

(Please select all that apply)

Describe the "Other" reason you were targeted *

What school do you currently attend? In what city/state?

What school were you attending when the incidents occurred? In what city/state? *

(If different from above)

Tell us more about what happened.

Please include the dates of when the incidents occurred, or your best estimate (such as, “sometime in Fall 2017”). *

Please tell us where the incidents occurred (such as, “on school bus”). *

Please tell us the names of any witnesses and names of all other people involved and what they did to you (such as, “Joe Smith often calls me ‘Gay’ and pushes me in the hallways at school”).

Did you report the incidents to any school employees? *

Yes
No

Please list their names and titles (such as, “Bob Johnson, vice principal”). *

Did you report the incidents to any outside agencies?

Yes
No

Please give us more details (such as, “filed complaint in October 2017 with the Department of Education Office for Civil Rights”). *

Time sensitive?

If you have any upcoming meetings or events related to the incidents that you would like us to be aware of, please indicate. (Such as, “Disciplinary hearing against my abuser scheduled for October 15, 2018.”)

Yes
No

Please provide details *

Please feel free to send us any documentation that supports your case.

Drop files here or

Accepted file types: pdf, docx, doc, csv, xls, xlxs, jpg, gif, png, Max. file size: 8 MB.

Next Steps

You should receive an e-mail confirming receipt of your online request for assistance the same day that it’s submitted.
Generally, your request for assistance will be reviewed by Public Justice within two (2) weeks of receipt (sooner, if time sensitive).
You may receive a follow-up phone call from a legal assistant, law clerk, or attorney to obtain additional information.