St. Johns Middle School Bullying Report
Please respond to questions you feel comfortable answering and are able to accurately answer. You may choose to include your name at the bottom of the form or may submit it anonymously. Please note that the district's ability to investigate an anonymous complaint may be limited, and the district prohibits retaliation against anyone who files a bullying report.
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Event *
When did it happen?
Date of event
MM
/
DD
Where did the bullying occur?
Please specify location(s).
Who committed the bullying?
If you don’t know the bully’s name(s) describe him/her.
Who was the victim of bullying?
If you don’t know his/her name, describe him/her.
Who witnessed the bullying?
Were you or others physically hurt?
Please explain.
Was there damage to property?
Please explain.
Routine changes?
Have you or the victim missed school or made changes to your daily routine because of this?
Who have you told about the bullying?
Have you previously filed a bullying report?
This information is used to determine if retaliation is occurring.
Contact Information
The next section allows us to follow up on your behalf.  You may choose to submit this form anonymously. Please note that the district's ability to investigate an anonymous complaint may be limited, and the district prohibits retaliation against anyone who files a bullying report.
Your name
Your grade:
Phone:
Email:
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