Bullying Report Form
"Bullying" means any aggressive and unwanted behavior that is intended to harm, intimidate, or humiliate the victim; involves a real or perceived power imbalance between the aggressor or aggressors and victim; and is repeated over time or causes severe emotional trauma. "Bullying" includes cyber bullying. "Bullying" does not include ordinary teasing, horseplay, argument, or peer conflict.
Code of Virginia § 22.1-276.01.
Student name who is repeatedly being bullied. *
Your answer
Student name who is repeatedly doing the bullying. *
Your answer
When did the repeated bullying incidents occur? *
Specific dates or how long repeated bullying has been going on.
Your answer
Where did the repeated bullying incidences happen. *
Check all that apply
Required
Type of bullying that occurred. *
Check all that apply
Required
Description of repeated bullying incident(s). *
Your answer
Witnesses (if any known)
Your answer
All reporting will go to the confidential file of the school counselors. After reviewing reports, appropriate school personnel will investigate and intervene appropriately based on determination of information gathered.
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