Bullying Incident Report Form
This Google Form is designed to allow students the opportunity to report incidents of bullying.

What is bullying?

Bullying, which includes cyberbullying, is any severe or pervasive physical or verbal act of conduct, including communications made in writing or electronically, directed toward a student or students that has or can be reasonably predicted to have the effect of one or more of the following:

- Place the student or students in reasonable fear of harm to the student's or students' person or property;
- Causing a substantially detrimental effect on the student's or student's physical or mental health;
- Substantially interfering with the student's or students' ability to participate in or benefit from the services, activities, or privileges provided by a school.

Your responses are anonymous. However, providing as much information as possible will help the school address any bullying that is occurring.

Who?
Who is involved? If you do not know the other person's name, describe them as best as you can.
Your answer
What?
What happened? Please give as many details as possible.
Your answer
When?
When did the incident, or incidents occur? If it has happened repeatedly, please let us know when it began.
Your answer
Where?
Where did it happen? If it happened at school, please give specific answers such as "Mr. Jones' classroom".
Your answer
Why?
There is no reason that bullying should occur. However, if there has been a history of ongoing issues, please tell us about those as well.
Your answer
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