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GSJSHS Bullying Report Form
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* Indicates required question
Email
*
Your email
Student Name
*
Your answer
Name of Person Involved
*
Your answer
Was the behavior carried out on purpose?
*
Yes
No
Was the behavior intended to cause harm? ( harm may be physical, verbal, relational, social/emotional, and/or via electronic communication)
*
Yes
No
Have there been patterned and consistent acts of this behavior? ( An average of 2 or more incidents per week, over the course of 2 or more weeks.)
*
Yes
No
Does the behavior include electronic communications that can be viewed at any time by multiple people?
*
Yes
No
Are you unable to stop the bullying behavior?
*
Yes
No
Any additional information?
Your answer
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