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.
Please check the appropriate box:
I am a parent
I am a student at JWHS
Please mark the box that best describes the situation you are reporting:
Someone I know is being bullied
I am being bullied
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.
The type of bullying that is occurring is:
repeated teasing or name calling
harrassment- racial, ethnic, sexual, religious
physical - pushing, poking, flicking, pinching, tripping
severe physical- punching, kicking, or similar behavior that could result in injury to others
threats of serious violence-(ie threat to use a weapon to cause harm) please contact an administrator or the safety hotline right away
cyberbullying- by texting
cyberbullying -by facebook or other social websites
Please describe the situation: WHEN is the bullying is occuring?
Please describe the situation: WHERE is the bullying is occuring:
Is there any other information that would be helpful for us to know?
If you are willing please leave a name, phone number, or email address for administration to contact and get more information.
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