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Bullying Reporting Form
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* Indicates required question
Your name if you want to include it. You don't have to.
Your answer
Your grade
*
6th
7th
8th
Parent
Staff
Other
Other:
Who was/were the person(s) being bullied?
*
Your answer
What day did the bullying take place?
*
Monday, this week
Tuesday, this week
Wednesday, this week
Thursday, this week
Friday, this week
last week
2 weeks ago
longer than 2 weeks ago
Other:
When did the bullying take place?
before school
between 8:00 and homeroom
homeroom
1st period
2nd period
3rd period
4th period
lunch
5th period
6th period
7th period
8th period
after 3:00
Other:
Clear selection
If the bullying occurred between classes, when did it happen?
Your answer
Who is/are the person/people doing the bullying?
*
Your answer
Where did the bullying happen?
*
In a classroom
In the hallway between classes
In the cafeteria
Gym/locker room
On the bus
At the bus stop before school
On the bus road after school
Other
What happened?
*
teasing
name calling
hitting, kicking,
shoving, pushing
gossip, rumors
making fun of the victim
Other (see below)
Other:
If you chose other, please describe what happened.
Your answer
Please describe what the bully(ies) said or did.
Your answer
Please list any other witnesses to this bullying.
*
Your answer
How many times has the bullying happened?
*
1 time
2 time
3-5 times
more than 5 times
Other:
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