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Bullying & Harassment Report
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First and Last Name
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Your answer
Who are you reporting on?
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Your answer
Where did the incident take place?
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Your answer
What date(s) did it happen?
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Your answer
Describe exactly what happened. Details are very important.
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Your answer
Has it happened before? If so when, where, and what?
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Your answer
Did you do anything to try and stop it?
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Your answer
Do you feel any of the following?
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Anxious it will happen again?
Afraid there will be retaliation?
Intimidated?
Afraid to come to school?
Other
Anything else you want to add to your report
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Your answer
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