You may use this form to report a conflict, bullying, or other inappropriate behavior. You may fill this out for yourself (if you are the target) or for someone else if you are being an Upstander
Your First Name
Your Last Name
What Grade are you in?
What is the name of the student (s) being targeted (first and last name)?
What is the grade of the student who is being targeted?
I don't know
What is the name(s) of the student(s) who was bullying or using inappropriate behavior (first and last name?)
What grade are they in?
I don't know
I want to report (you may check more than one)
Sexual or Sexist Words
Touching private parts of the body
Where did this happen?
On the bus
On the Field
PE Locker Rooms
Classroom (be sure to indicate which period in the next question)
If this occurred during class time, which period?
If this occurred during class time, which teacher's class was it?
What was the date that this happened?
What time of day did this happen
During passing period
On the weekend
How often is the behavior happening?
Has only happened once
Very Often (almost daily)
How bad is the behavior?
It is annoying
I do not want to come to school until it stops
How safe do you feel when you are at school?
You may choose to tell what happened in more detail
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