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Scotland County Schools Bullying Report
Shaw Academy School
Have you reported this event to anyone in authority?
This could include a teacher, principal, or staff member at a school.
Name of person allegedly being bullied.
Please put first and last name if known
Your answer
Alleged location:
Where did this incident take place?
Date of alleged incident
Your answer
Name of alleged bully.
(if known)
Your answer
The alleged bully is a:
Your name.
This question is optional.
Your answer
I am a:
What occurred?
Please check all that apply.
Description of event
Please be specific and include location, date, and time
Your answer
Did you witness the event?
If you did not witness the event, how were you made aware of what happened?
Your answer
Please list other students/staff who witnessed the event.
Your answer
Additional comments:
Your answer
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