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Bullying Report Form
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
MM
/
DD
/
YYYY
I am a:
Student
Parent/Guardian
Staff Member
Other:
Clear selection
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
Clear selection
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
Clear selection
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
No
Clear selection
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