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Anonymous Bullying Report
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* Indicates required question
What date did the bullying incident occur?
*
MM
/
DD
/
YYYY
Who is the target/victim of the bullying incident? Please give first and last name.
Your answer
Name of the alleged aggressor/offender(s) of the bullying incident? Please give first and last name(s).
*
Your answer
Where did the incident happen? Check all that apply.
*
On school property
At a school-sponsored activity
At a bus stop
On a school bus
On the way to/from school
On a computer/cellphone/other electronic device
Other:
Required
Put a check next to the statement(s) that best describe(s) what happened
teasing
threat
physical violence
name calling
social exclusion
intimidation
theft
sexual harrassment
cyber bullying
stalking
public humiliation
What did the alleged aggressor/offender(s) say or do?
Your answer
Did physical injury result from this incident?
No
Yes (If yes, please explain below)
Clear selection
Please explain any physical injury as a result of this incident.
Your answer
Did the injury require medical attention
No
Yes (If yes, please explain below)
Clear selection
Please explain any medical attention required as a result of this incident.
Your answer
Was the target/victim absent from school as a result of this incident?
No
Yes
Clear selection
If the victim was absent from school as a result of this incident, how many days were they absent?
Your answer
Please indicate how you know about this incident
I witnessed
I heard about it
Other:
Clear selection
School(s) involved and to be notified
*
Check all that apply. If unsure, leave blank.
Watertown High School
Watertown Middle School
Lowell Elementary School
Hosmer Elementary School
Cunniff Elementary School
Other:
Required
Is there anything else we should know about this incident? You may optionally give your name if you wish.
Your answer
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