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CES Bullying Report Form
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* Indicates required question
Name of Alleged Bully
*
Your answer
Your Name (OPTIONAL)
Your answer
I am a
*
Student
School Employee
Parent/Guardian
Person Being Bullied
Community Member
Other
Type of Event (Select all that Apply)
Select at least 1 and no more than 0.
*
Physical-Hitting/kicking/other physical aggression
Verbal- Teasing, name-calling, put downs, or other behavior that would hurt others
Emotional/ Exclusion-Starting rumors, telling others not to be friends with someone, or other action
Cyber Bullying - Using an electronic medium to engage in any previously mentioned bullying
Other
Required
Please describe the events (Be specific - include date, time, specific location)
*
Your answer
Did you witness the event?
*
Yes
No
If YES, list any other witnesses to the event
Your answer
If NO, how did you learn of the event
Your answer
I have reported this event to my school
Yes
No
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