Student Bullying Report Form
Instructions: Please complete all questions, responding only to the questions that you feel comfortable answering and are able to accurately answer. You may choose to include your name at the bottom of the form or may submit it anonymously. Please note that the district's ability to investigate an anonymous complaint may be limited, and the District prohibits retaliation against anyone who files a bullying report.
Any behavior that can be classified as being so severe, pervasive, or objectively offensive that it substantially interferes with the student's educational opportunities; places the student in actual and reasonable fear of harm; places the student in actual and reasonable fear of damage to property of the student; or substantially disrupts the orderly operation of the public school. *
Describe what happened/what is happening:
Your answer
Where did it happen?
When did it happen?
Date of the occurrence
Your answer
Time of the occurrence
Your answer
Who was committing the bullying (if you don't know the bully's name(s) describe him/her)?
Your answer
Who was the victim of the bullying (if you don't know his/her name, describe him/her)?
Your answer
Did anyone else witness the bullying?
If you answered Yes to the previous question, please list those who witnessed the bullying.
Your answer
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