Bullying Report Form
Definition of Bullying: Intimidating, threatening, abusive, or harming conduct. An actual or perceived imbalance of power exists between the student engaging in bullying and the students being bullied. The conduct is repeated or forms a pattern. It may interfere with the student’s educational opportunities or the ability to participate in school activities.

The complete policy can be found on the White Bear Lake Area School's website under the following tabs:
*About
*School Board
*District Policies
*Policy 514 (500 Series)

Person Filling Out Report
Please enter your name below. (Note: Per Minnesota Statute, no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report)
Your answer
Contact Information
(Please add your phone number or any additional information which may be useful in the event we need to contact you)
Your answer
Check whether you are:
Check whether you are:
Required
Nature of alleged Bullying (Check all that apply):
Required
Date of Incident(s):
MM
/
DD
/
YYYY
Time the Incident(s) Occurred?
Time
:
Location of Incident(s)
(Check all that apply):
Required
Please further specify location
Your answer
Who was allegedly Bullied?
(Please list the first and last names and grade levels of all students allegedly being bullied)
Your answer
Who did the alleged Bullying?
(Please list the first and last names and grade levels of all students allegedly taking part in the bullying)
Your answer
Describe the details of the incident
(Include the names of people involved (including witnesses), what occurred, and what each person did and said, including specific words used or actions taken).  
Your answer
Has this happened before?
If yes, please describe previous incident(s):
Your answer
Is there any physical evidence?
(Check all that apply)
Is there any other information we need to know?
Your answer
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