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.
Your Name:
This step is optional but please remember the more information the school has the better they can handle the incident.
Your answer
Are you a... *
Where did the incident take place? *
Is this the first incident? *
If no, please explain
Your answer
What type of bullying occured? *
Check all that apply
Required
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.
Your answer
Time of incident
This is not a required question, however your best estimate would be helpful
Time
:
Date of incident *
MM
/
DD
/
YYYY
Name of Victim *
Your answer
Name of primary student targeting victim. *
*list one name only
Your answer
Any additional students targeting victim within the same incident.
*list all names that apply
Your answer
Please describe the incident with as much detail as possible. *
Your answer
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