Student Bullying Report Form
Respond to the questions that you can accurately and comfortably answer. You may choose to include your name at the bottom of the form or may submit it anonymously; however you must indicate the school you attend.

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.

Describe what happened/what is happening
Please be as detailed as possible.
Your answer
When did/does this bullying occur?
Your answer
Where does/did this happen?
Your answer
Who was committing the bullying?
If you don't know his/her name, please describe to the best of your ability.
Your answer
Who was being bullied?
if you don't know his/her name, please describe to the best of your ability.
Your answer
Did anyone else witness the bullying?
If yes, please list.
Your answer
Were you or others physically or emotionally hurt as a result of the bullying?
If yes, please explain.
Your answer
Was there damage to anyone's personal property?
If yes, please explain.
Your answer
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)?
Your answer
Have you told anyone about the bullying?
Example: parent, babysitter, brother/sister, teacher, family member, etc.
Your answer
Has this happened before?
If yes, please indicate number of times and details
Your answer
Your name
Optional; but helpful if necessary for further follow-up
Your answer
Your Grade
Email address
Your answer
Are you willing to, or do you wish to, visit with Administration or a Counselor about this incident?
If you said "yes" to the previous question - With whom would you prefer to talk to directly.
Your answer
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