Bully and Safety Reporting Form
The purpose of this form is to provide an opportunity for students and parents to report unsafe behavior in hopes of maintaining our school as a safe and positive environment for all students. This form is meant to be used for incidences that occur on school grounds.
First Name *
Your name can remain anonymous when we follow up with identified students.
Your answer
Last Name *
Your name can remain anonymous when we follow up with identified students.
Your answer
School *
Required
I am a... *
Grade Level *
If you are a parent, please indicate the grade of your child.
Required
Date and Time of the incident *
If there have been multiple incidences, identify the most recent.
MM
/
DD
/
YYYY
Time
:
Type of incident *
Required
Target(s)/Victim(s) in the incident(s) *
List names
Your answer
Student(s) engaging in the behavior *
List names of students who are bullying or being unsafe
Your answer
Witnesses
List names
Your answer
Location of incident *
Briefly describe what happened *
Your answer
Has this behavior happened before? *
Required
If so, how many times?
Have you discussed this with a parent/guardian? *
Required
Have you discussed this with a staff member? *
Required
If yes, who?
Your answer
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