MES/MJH Bullying Report Form
Please report any bullying incidents you feel may be going on at school. All reports will be investigated by the administration.
* Required
Your name
*
Your answer
Location of Bullying
*
Where did you experience or witness bullying take place?
In your classroom
In the hallway
On the playground
In the locker room
Outside of the school day
On the internet (cyber bullying)
Other:
Type of Bullying
*
What did you experience or witness?
Verbal bullying (using words)
Physical bullying (pushing/hitting)
Emotional bullying (exclusion/dirty looks)
Cyber bullying (on the internet)
Required
Your Role in the Bullying
*
Target (victim)
Bully
Witness (bystander)
Please name target(s).
*
Who was being bullied?
Your answer
Please name the bully/bullies in this incident.
*
Your answer
Please list any bystanders that witnessed the incident.
*
Your answer
Please describe what happened using as much detail as you can.
*
Your answer
Did you report this incident to an adult?
*
Yes
No
If your reported the incident to an adult, please name that person.
Your answer
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