Bullying is REPEATED use by one or more students of a written, verbal or electronic expression or a physical act or gesture or any combination thereof, directed at the victim that causes or places the victim in reasonable fear of harm to himself or of damage to his property, creates a hostile environment at school for the victim, infringes on the rights of the victim at school, or disrupts the education process.
Cyber-bullying is bullying through the use of technology or any electronic communication, which shall include but is not limited to electronic mail, internet communications, instant messaging, posting on social networking sites, or facsimile communications.
Date of report: *
Name of person reporting the incident.
(Leave blank if you wish to remain anonymous).
If you are the person who suffered from the incident, then select Target. If you are reporting the incident, then select Reporter.
You are the: *
You are a(n): *
Your contact information/telephone number:
(Leave blank if you wish to remain anonymous).
Which school or work site should receive this report?
School or work site: *
If the target is a student, please state which grade the student is in.
Name of the person(s) who suffered the aggression.
Target(s): *
Name of the person(s) who committed the aggression.
Aggressor(s): *
Date of incident: *
Time of incident: *
Location of incident (be as specific as possible): *
List people who saw the incident - Bystanders.
Bystander (1):
What is the role/position of the Bystander?
Position (1):
Clear selection
Bystander (2):
Position (2):
Clear selection
Bystander (3):
Position (3):
Clear selection
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).
What happened? *
Never submit passwords through Google Forms.
This form was created inside of Lowell.k12.ma.us. Report Abuse