Bullying Report Form

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Complete the form below to report bullying. Please note that the 'Your name' field is optional for those who prefer to remain anonymous. Completed forms will be sent to the school's principal and assistant principal for review.

Your name (optional)

I am a *

check one

Student

Parent/Guardian

Community Member

Staff Member

Person being bullied

Friend

Required

Today's date *

YYYY

Name of person being bullied *

Type of bullying *

Physical: Hitting, kicking, damaging property, or other physical aggression

Verbal: Teasing, name-calling, put-downs, or other behavior that would hurt another's feelings

Emotional/Exclusion: Starting rumors, telling others not to be friends with someone, or other actions

Cyber-bullying: Using any electronic device to bully

Required

Description of events *

please be specific

Location of event *

Classroom

Hallway/Breezeway

Playground

Cafeteria

Bus

Gym

Office

Bathroom/Restroom

Common Area

Library

Music Room

Off-Campus

Art Room

Bus Loading Zone

Computer Lab

Special Event/Assembly/Field Trip

Parking Lot

Locker Room

Vocational Room

Stadium

Other:

Required

Time of event *

Time

Date of event *

YYYY

Other students or staff who witnessed the bullying *

Submit

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