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.
Today's Date *
MM
/
DD
/
YYYY
Name of Reporting Party *
Please write your first AND last name.
Your answer
Are you a student, parent, staff member, etc? *
How did you obtain this information? *
Required
Name of the Target (Victim) *
Please list the first and last name of the person who has been bullied.
Your answer
Teacher
Please list the teacher of the student who has been bullied, if known.
Your answer
Name of the Aggressor (Bully) *
Please list the first (and last if known) name of the aggressor (bully)
Your answer
Teacher of the Aggressor (Bully) if Known
Please list the name of the teacher of the aggressor if known.
Your answer
Bystanders (Witnesses) if Known
Please list the names of any bystanders who witnessed the bullying behavior.
Your answer
Approximate Time of Incident *
Check any that apply.
Required
Location of Incident *
Check any that apply.
Required
Type of Bullying *
Check all that apply.
Required
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? *
Required
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.
Your answer
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.
Your answer
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