Bullying Report Form
If this is an emergency or if you are at risk of immediate harm, please tell your teacher, your parent, the principal, and/or the counselor immediately; or call the office at 297-2240.
Please answer each of the following questions. What you report here goes directly and only to the principal and the school counselor. The information will be kept confidential to the extent possible.
The person making this report is:
There are 7 drop-down menu choices, below. If you are a student, you will choose "student victim" if the unwanted behavior or the bullying happened to you. You will choose "a student witness" if you saw the bullying but it was not done to you. You will choose " a student who heard about the bullying..." if you were not there when the behavior happened.
a student victim
a student witness
a student that heard about the bullying from someone else but did not see it
a staff member
a community member
What is your name?
Giving us your name is optional, but providing your name would be helpful. We will keep your name confidential if you do share it with us. If a student, you may choose to give us your PowerSchool number, instead.
Write the name of the person or persons who did the bullying or carried out the unwanted behavior.
Mark the behaviors that you found upsetting, aggravating, disrespectful, and/or mean.
Check all that apply
Aggressive by hitting or kicking
Asking other students to not be your friend
Using profanity or cussing
Other unwanted physical touching
Cyber bullying (texting, e-mail, Facebook, etc)
What time did this unwanted behavior happen?
Please write the time when this event took place (for example: 1:15pm). If you don't know the exact time, write the general time span when the behavior happened (for example: 9:45 - 10:30).
On what day and date did this unwanted behavior happen?
Please put the day and date (for example: Tuesday, October 23). If you don't remember the exact date, put down as close as possible to the date you think it happened (for example: I think it happened either Thursday or Friday on October the 18 or 19.)
Where did the unwanted behavior occur?
Did this happen in the classroom, in the hallway, in the cafeteria, on the play ground, in the gym, on the bus, or somewhere else?
in the classroom
in the hallway
in the bathroom
n the media center
in the computer lab
in the cafeteria
in the gym
on the playgound
on the bus
Who was around at the time who may have seen or heard what happened?
Who witnessed the event? Who else was there when the event happened?
Describe in the box below what happened.
Begin at the beginning. Be sure to include as many details as possible.
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This form was created inside of Watauga County Schools.