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Patriot Safety Report
Please fill out this form to the best of your ability. You can leave blanks, but with more information there is a better chance of a positive result.
Date of Report
MM
/
DD
/
YYYY
Your Name (optional)
Your answer
Your Grade
Person You are Concerned About
Your answer
That Person's Grade
Bully's Name
Your answer
Bully's Grade
Names of Witnesses (if any)
Your answer
Date of most recent incident
MM
/
DD
/
YYYY
How long has this been going on?
How many times has the student/target been harassed by this bully?
Location (check all that apply)
Tattling vs Reporting Tattling = Wanting to get someone else in trouble or to get attention (Inappropriate/False Report) Reporting = Helping yourself or others to stay safe (Appropriate/True Report) Please provide specific details regarding the Incident(s):
Your answer
ANY FALSE REPORTS WILL RESULT IN DISCIPLINARY ACTION(S) FROM THE SCHOOL AND/OR THE ST. TAMMANY SCHOOL BOARD
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