Southwest Middle School Bullying and Harassment Reporting Form
Click "Submit" to send the information after you answer the questions below. Your report will be kept confidential.
First Name of the person acting like a Bully?
Last Name of the person acting like a Bully?
First name of student being bullied.
Last Name of student being bullied.
Where did the Bullying occur?
When did this occur? (Date)
When did this occur? (Time)
Type of Bullying or Harassment
Physical- hitting, kicking, other physical aggression
Verbal - teasing, name calling, put-downs, other behavior that would hurt others' feelings or make them feel bad.
Emotional- exclusion, starting rumors, telling other not to be friends with someone
Cyber bullying- using an electronic medium to engage in any previously mentioned bullying.
Please add any additional information that you need to share. Describe what you witnessed or what the student reported to you.
Have you reported the bullying to another adult at school? If yes, please enter their name below.
Your name (optional)
I am a ...
Did you witness the bullying?
Who else witnessed the event? (First and Last name)
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