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.
Name of the Person being bullied (First and Last Name)
Name of the Person who is acting like a bully (First and Last Name).
Where did the Bullying Occur?
When did this occur? (Date and Time)
Type of Bullying or Harassment (Select all that apply)
Physical ---hitting, kicking, other physical aggression.
Verbal--teasing, name calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad.
Emotional --Exclusion- starting rumors, telling others not to be friends with someone or other actions that could cause someone to be without friends.
CyberBullying-- 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)
Send me a copy of my responses.
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