Ada Schools Anonymous Bullying Reporting Form 16-17
If you have information regarding bullying and would like to report this information anonymously, please fill out the following form to the best of your knowledge. Please note that this form is completely anonymous.
What date did the bullying incident occur?
Your answer
Victim Name
Who was bullied?
Your answer
Accused Name
Who was the bully?
Your answer
Where did the incident happen?
Check all that apply
Put a check next to the statement(s) that best describe(s) what happened:
Check al that apply
Please describe, in as much detail as possible, what happened.
Your answer
Do you know any of the witnesses involved? If so, please provide as much detail as possible about these people.
Your answer
Is this report based on your honest belief that the student listed above as the victim has been bullied/cyberbullied and, to the best of your knowledge, is the information submitted a true and accurate representation of events? *
Please Note:
Students are prohibited from deliberately making false reports of bullying, harassment, threats, or intimidation. Those who make false reports will be subject to disciplinary action according to the Code of Conduct and Ohio Revised Code.
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