Anonymous Bullying Report
I am a
During the incident I was a
What is your name?
THIS IS OPTIONAL
Your answer
If you are a student, what grade are you in?
What is the name of the student you would like to report. If you do not know the name of the student, please describe them.
Your answer
When did this incident take place?
Wed., 9/10/14 at around 10 am
Your answer
Where did the incident take place? Please be specific.
In the back half of bus 228
Your answer
Please describe the incident. Give details and be as specific as possible.
Your answer
Were there witnesses to the incident?
What were the names of the witnesses?
Your answer
Please rate the severity of this incident from your perspective, 1 being minor incident but unacceptable to 5 being major incident that could result in retaliation or violence.
Please describe the frequency with which this type of incident occurs.
ex. everyday, once a week, once a month, etc.
Your answer
How do you feel about this incident or person?
(Examples: they are annoying, I hate them, I want to hurt them, they don’t make me mad I just want it to stop…etc)
Your answer
Did this or other incidents make you feel like harming yourself or others?
Would you like to speak with a counselor?
What else would you like us to know about this incident? Is there anything that you haven't been able to share above that is important to know.
Your answer
Please describe any evidence that exists of the bullying (letters, photos, texts, etc). If you can provide this, please leave with someone in counseling office
Your answer
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