Bullying Form
If you feel that you have been bullied or have heard about or witnessed a bullying event, please fill out this form
Your Name (OPTIONAL)
Your answer
Has this incident been reported already? *
Date and time of the bullying incident (best guess if not sure) *
MM
/
DD
/
YYYY
Time
:
If this bullying incident took place inside the school, which side did it take place on? *
Name of victim(s) (OPTIONAL):
IF MORE THAN 1 NAME, USE COMMA (,) AND PUSH ENTER AFTER EACH NAME PLEASE
Your answer
Name of person(s) doing the bullying: *
IF MORE THAN 1 NAME, USE COMMA (,) AND PUSH ENTER AFTER EACH NAME PLEASE
Your answer
Name of witnesses/bystanders?
IF MORE THAN 1 NAME, USE COMMA (,) AND PUSH ENTER AFTER EACH NAME PLEASE
Your answer
Location of bullying incident? *
If this bullying incident happened in a classroom, please let us know which room number:
Your answer
How often and for how long has the bullying been going on? (Please explain below)
Your answer
What type of bullying occurred? *
Required
Description of the bullying incident ~using concrete, clear wording: *
Your answer
If you know what led to this bullying incident, please state below:
Your answer
Was the incident reported to an adult? *
If you answered yes to the above question, please let us know who the bullying incident was reported to:
Your answer
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