Elk Point-Jefferson Bullying Report Form
*Use this form to report any incidents of bullying seen by you or happening to you.
Date of Report *
MM
/
DD
/
YYYY
Name of Person(s) Being Bullied: *
Your answer
Name(s) of Alleged Bully(s): *
Your answer
Reporter Name(s): Optional
Your answer
Name(s) of Witness(es):
Your answer
Description of Events: (Please be detailed and specific as to what happened. Make sure to describe when (date), where (at school, on the bus, at a school activity, at home, etc.), and what time (ex: 2:15 pm) the event happened. Describe the events (i.e. shoving in the hallway, spreading rumors, locker room intimidation, text messages, Snapchat, etc.) as best you can. *
Your answer
How often has this occurred? How long has this been happening? *
Your answer
Describe any steps taken to address the behavior with the alleged bullying person, i.e. asked the person to stop. *
Your answer
All bullying is serious and we appreciate your help in addressing the behavior and protecting all of our students and staff. Remember that bullying is defined as a pattern of repeated conduct that causes physical hurt or psychological distress on one or more students that may include threats, intimidation, stalking, physical violence, theft, destruction of property, any threatening use of data or computer software, written or verbal communication, or conduct directed against a student that: Places a student in reasonable fear of harm to his or her person or damage to his or her property; Substantially interferes with a student's educational performance; or Substantially disrupts the orderly operation of a school; or Retaliation against a student for asserting or alleging an act of bullying. Do you have anything else to add which you believe would provide more information to this situation? *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of State of South Dakota K-12 Data Center. Report Abuse - Terms of Service - Additional Terms