Bullying Report Form

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Bullying is a serious issue and will not be tolerated. Use this form to report bullying that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; on the way to and/or from school; on social media or through text message, during the current school year. If you are a student or a friend of a student is who is being bullied and wish to report an incident of bullying, complete this form.

While the form below may be submitted anonymously, it would be helpful to the investigation process to have the names of all people involved including the name of the person submitting the form.

We appreciate your assistance in helping us maintain a safe community of learning in the Clinton School District.

Your Name

Your answer

Date

YYYY

I am a:

Student

Parent/Guardian

Staff Member

Other:

Phone number (optional)

Your answer

Email address (optional)

Your answer

Student who was bullied:

Your answer

Student who did the bullying:

Your answer

Date and time of incident:

Your answer

Location of incident:

Your answer

Type of bullying being reported:

PHYSICAL: Acts such as hitting, spitting, kicking or damaging your or another students' possessions

VERBAL: Saying mean or hurtful things or threatening you or another student

SOCIAL: Excluding you or a student from a group, telling peers not to talk to you or another student

EMOTIONAL: Spreading mean rumors or lies about someone

CYBER/ONLINE: Occurs on a website or social media, by cell phone, email or text message

Other

Did the bullying include mean comments about you or other students'?

Physical appearance

Academic performance

Race/ethnicity or perceived race/ethnicity

Sexual orientation or perceived sexual orientation

Gender or gender expression

Religious or cultural beliefs

Please give any other details about the incident that you feel are important.

Your answer

Were there any witnesses? If so, who?

Your answer

Are you afraid to come to school

Yes

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