JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Bullying Report
Sign in to Google
to save your progress.
Learn more
* Indicates required question
School Name
*
Choose
Burnett Elementary
Calaveras Hills High
Curtner Elementary
Milpitas High
Pomeroy Elementary
Rancho Middle
Randall Elementary
Rose Elementary
Russell Middle
Sinnott Elementary
Spangler Elementary
Weller Elementary
Zanker Elementary
Where did the incident occur?
*
¿Donde sucedió este incidente?
Bathroom
Cafeteria
During Class
Email
Gym
Hallway / School Area
Instant Message (AIM / Google / etc.)
Parking Lot
Social Media (Facebook / Myspace / Google+ / Twitter / YouTube / etc.)
Text Message
Other:
Required
Type
*
¿tipo?
Physical Harassment
Sexual Harassment
Verbal Harassment
Other:
Required
When did it happen? (Time & Date)
¿Cuando ocurrió esto?
Your answer
Who was bullying, harassing, intimidating, or causing harm? (include first name, last name, and grade if known)
*
¿Quien estaba intimidando, acosando, o causando daño? (incluya nombre, apellido, y año escolar si lo sabe)
Your answer
Who was the person being harmed, bullied, harassed, or intimidated? (include first name, last name, and grade if known)
*
¿Quien era la persona siendo dañada, intimidada, acosada o amenazada? (incluya nombre, apellido, y año escolar si lo sabe)
Your answer
Were there any witnesses? Please list their names.
¿Hubo algún testigo? Favor de notar sus nombres.
Your answer
Is there video proof? Please provide a link.
¿Hay pruebas de vídeo? Sírvase proporcionar un enlace.
Your answer
Describe what happened. Give as much information as you can.
*
Describe que paso. Da la mayor cantidad de información posible.
Your answer
Reporter Information
Información sobre la persona reportando
Are you a
*
Eres
Choose
Administrator
Board Member
Community Member
Parent
Staff
Student
Volunteer
Other
What is your name (optional)
Please note: Anonymous reports are accepted however they must provide sufficient evidence to justify the commencement of an investigation. Formal disciplinary action may not be based solely on an anonymous complaint. ¿Cual es tu nombre (opcional)? Favor de notar: Informes anónimos son aceptados sin embargo deben proporcionar suficiente evidencia para justificar el inicio de una investigación. Acción disciplinaria formal no puede estar basada simplemente en una queja anónima.
Your answer
If you are not a student at this campus and would like someone to contact you, please add your phone number or email here. (Optional)
Si usted no es alumno en esta escuela y gustaría que alguien se comunicara con usted, favor de añadir su número telefónico o email aquí (opcional)
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of MUSD.
Report Abuse
Forms
