Bully Report

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Bully Report

Please pick one of the boxes below to let us know if you are the victim of bullying or if you are a witness to bullying. *

I am a victim of bullying and I want help.

I saw another student being bullied and I want to help.

Required

What is today's date? *

YYYY

What is your name?

If you do not wish to put your name, please put the lunch number in the box at the end of this report so that we can follow up.

What grade and team are you on? *

Grade 6: Eagles

Grade 6: Falcon

Grade 6: Hawk

Grade 7: Fire

Grade 7: Ice

Grade 7: Water

Grade 8: Seawolves

Grade 8: Raiders

Please provide the name/names of the bully/bullies. *

Please give us the names of who bullied you. If you only know the students last name or grade, include that.

Please check off any of the boxes below that apply to this bullying incident. *

Check all that apply.

Name calling or put down

Comment which is sexual in nature

Exclusion from a group (Example: You cant sit here, sit over there)

Being blackmailed for money or possessions (Example: If you don't give me your money I will tell on you)

Implied threat (Example: I would hate to have to hurt you if you don't give me your money)

Stated threat (Example: I will hurt you if you don't give me your money)

Assault (This means being hit or attacked)

Blocking movement to where you want to go (Example: Someone blocking your way to the bathroom)

Offensive touching (being touched in a way that makes you uncomfortable)

Visual insult (Example: mocking the way someone walks)

Verbal taunt: Called names or antagonized in an effort to start a fight

Other:

Required

Please give a description, IN FULL DETAIL, of the bullying incident which you checked off from above. *

The more details, the better. Using words, we want you to "Paint a picture" of what happened. In other words, don't just say "I got hit." Instead, use details and say, I was punched in the face and stomach. Don't write "She was messing with me." Instead give us details and say "She called me ______ and said I _______."

Please give the names of any witnesses who saw the incident.

Finally, how did this make you feel? *

Please enter your lunch number below so that we can talk to you about this incident. *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of McDowell County Schools. Report Abuse

Forms