Pine Island Bully Reporting Form Grades 5-12
Before filing an official bully report, we would like you to make sure that what you are reporting is bullying and not another type of incident. Please complete the pre-questions before filing the report. In order to be bullying, the incident needs to fall under all 3 of the following criteria.
Pre-Question 1-Have the incidents occurred more than once? Please list approximate dates of the multiple incidents.
Your answer
Pre-Question 2-Is there an imbalance of power? Please explain the imbalance.
Your answer
Pre-Question 3-Have the incidents affected your life at school? Please explain how your school life has changed since the incidents began.
Your answer
Reporter Name
Your answer
You are reporting as:
Date Of Incident
MM
/
DD
/
YYYY
Name of Student(s) to whom the bullying was directed
Your answer
Name(s) of students who engaged in the bullying
Your answer
Location of Incident
Your answer
List any witnesses
Your answer
Description of the incident
Your answer
Check any that apply if the bullying was directed at another student due to the student's actual or perceived:
Did the bullying occur through electronic communication?
If so, explain the type or form of communication
Your answer
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