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Scotland County Schools Bullying Report
Wagram Elementary School
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* Indicates required question
Have you reported this event to anyone in authority?
This could include a teacher, principal, or staff member at a school.
Yes
No
Clear selection
Name of person allegedly being bullied.
*
Please put first and last name if known
Your answer
Alleged location:
*
Where did this incident take place?
at school
on bus
at bus stop
athletic event
Other:
Required
Date of alleged incident
*
Your answer
Name of alleged bully.
(if known)
Your answer
The alleged bully is a:
*
student
school employee
Other:
Your name.
This question is optional.
Your answer
I am a:
*
student
school employee
parent/guardian
person being bullied
concerned citizen
friend
Other:
Required
What occurred?
*
Please check all that apply.
Physical: Hitting, kicking, or other physical aggression
Verbal: Teasing, name-calling, put-downs, or other behavior that would hurt others'feelings or make them feel bad
Exclusion: starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends.
CyberBullying: Using a computer, cell phone, or other electronic device to engage in any previously mentioned bullying.
Other:
Required
Description of event
*
Please be specific and include location, date, and time
Your answer
Did you witness the event?
*
yes
no
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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