Bullying Report 16-17 Form
This form is an anonymous way for students or parents to report to administration incidents of bullying that they are experiencing or have witnessed. We hope that this will provide us one more tool to help all students feel welcome and safe at Jefferson West High School. If this is an emergency please contact the administration directly or call the safe schools hotline at 1-877-626-8203.
My name is?
You may give us ths information if you would like, it is NOT required to submit this form.
Your answer
Today's date: *
Your answer
Please check the appropriate box: *
Please mark the box that best describes the situation you are reporting: *
The name of the bully (bullies) is (are): *
Please give first and last name, if you don't know name- describe them the best you can: grade, ht, wt, hair color, who they hang out with, etc.
Your answer
The type of bullying that is occurring is: *
Please describe the situation: WHEN is the bullying is occuring? *
Your answer
Please describe the situation: WHERE is the bullying is occuring: *
Your answer
Is there any other information that would be helpful for us to know?
Your answer
If you are willing please leave a name, phone number, or email address for administration to contact and get more information.
Your answer
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