Bully Prevention Reporting Form Juniper Elementary 2017-2018
THIS FORM SHOULD BE USED TO REPORT PURPOSEFULLY HURTFUL BEHAVIORS THAT PERSIST AFTER AN AGGRESSOR HAS BEEN ASKED TO STOP.
Name of Reporting Party
Please write your first AND last name.
Are you a student, parent, staff member, etc?
How did you obtain this information?
It happened to me.
I witnessed it.
The target (victim) told me about it.
A bystander (witness) told me about it.
Name of the Target (Victim)
Please list the first and last name of the person who has been bullied.
Please list the teacher of the student who has been bullied, if known.
Name of the Aggressor (Bully)
Please list the first (and last if known) name of the aggressor (bully)
Teacher of the Aggressor (Bully) if Known
Please list the name of the teacher of the aggressor if known.
Bystanders (Witnesses) if Known
Please list the names of any bystanders who witnessed the bullying behavior.
Approximate Time of Incident
Check any that apply.
During the school day, before lunch
During lunch or lunch recess
During the school day, after lunch
Location of Incident
Check any that apply.
Walking to or From School
Type of Bullying
Check all that apply.
Verbal (name-calling, teasing, insults, sexual or racial comments)
Intimidation (threats, taking or damaging possessions, purposeful exclusion)
Cyber (online bullying via texting or social media)
Physical (physical aggression, physical assault)
Has the target (victim) asked the aggressor (bully) to stop the behavior?
Has the target (victim) reported the incident to a staff member? If so, to whom?
Yes, it was reported to a teacher. (Please list the teacher name under other if known.)
Yes, it was reported to a proctor. (Please list the proctor name under other if known.)
Yes, it was reported to an administrator.
Yes, it was reported to a bus driver.
No, it was not reported to a staff member.
Description of Incident
Please describe what happened. Please include details about how the aggressor has been asked to stop, or informed that his or her behavior was hurtful or unwanted.
PARENTS: IF YOU WOULD LIKE TO RECEIVE A TEXT MESSAGE TO CONFIRM THAT THIS FORM HAS BEEN RECEIVED, PLEASE LEAVE YOUR NAME AND CELL PHONE NUMBER BELOW.
STUDENT REPORTERS WILL BE CONTACTED IN PERSON AT SCHOOL.
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