Havana Junior High Bullying Report Form
Only complete this form after you have read the district definition of bullying and are confident that the incident fits within those guidelines. A false report of bullying is a serious offense and will be met with consequences at the Principals discretion.
This step is optional but please remember the more information the school has the better they can handle the incident.
Are you a...
School Staff Member
Where did the incident take place?
PE Locker Room
Gym during PE
Parking Lot Area
Extra Curricular Activity
General Locker Area
Is this the first incident?
If no, please explain
What type of bullying occured?
Check all that apply
If you checked "Physical" on previous question please use this space to specify injury and who it was reported to at the time of the incident.
Time of incident
This is not a required question, however your best estimate would be helpful
Date of incident
Name of Victim
Name of primary student targeting victim.
*list one name only
Any additional students targeting victim within the same incident.
*list all names that apply
Please describe the incident with as much detail as possible.
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