Bloomfield- Mespo Local Schools Student Bullying Report Form
Please complete all questions, responding only to the questions that you feel comfortable answering and are able to accurately answer. You may choose to include your name at the bottom of the form or may submit it anonymously. Please note that the district's ability to investigate an anonymous complaint may be limited, and the School District prohibits retaliation against anyone who files a bullying report.
Please select/write today's date. *
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Describe what happened/what is happening: *
Your answer
When did it happen? *
Your answer
Where did it happen? *
Your answer
Who was committing the bullying (if you don't know the bully's name(s) could you describe him/her? *
Your answer
Who was the victim of the bullying (if you don't know their name(s) could you describe him/her? *
Your answer
Did anyone else witness the bullying? If so please list their names. *
Your answer
Were you or others physically hurt? (Please explain) *
Your answer
Was there damage to anyone's personal property? (Please explain) *
Your answer
Who have you told about the bullying? *
Your answer
Have you previously filed a bullying report about this person? *
Name
Your answer
Grade and Age *
Your answer
How can we contact you? (Please include phone number or email)
Your answer
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