JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Report Bullying 19-20
Bernal Intermediate School
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Incident Information
Where did the incident occur?
*
Choose
In a text message
In a voicemail
In an instant message
In a classroom
In front of school
In a hallway
In the bathroom
In the forum
In the small gym
In the new/big gym
In the locker room
In the library
On the bus
On the turf/field/blacktop
Off campus
On Facebook
On YouTube
On Twitter
Other
Type of incident
*
Choose
Physical Harassment
Sexual Harassment
Verbal Harassment
Other
What day did it happen?
*
MM
/
DD
/
YYYY
Approximately what time did it happen?
Time
:
AM
PM
Who was bullying, harassing, intimidating or causing harm? (Include first name, last name and grade if known)
Your answer
Who was the person being harmed, bullied, harassed or intimidated? (Include first name, last name and grade if known)
Your answer
Were there any witnesses? Please list their names here.
Your answer
Describe what happened. Give as much information as you can.
*
Your answer
Reporter Information
Are you a:
*
Choose
Student
Teacher
Staff Member
Administrator
Board Member
Volunteer
Parent
Other
What is your first and last name? (Optional) Please note: Anonymous reports are accepted however they must provide sufficient evidence to justify the commencement of an investigation. Formal disciplinary action may not be based solely on an anonymous complaint.
Your answer
If you are not a student at this campus and would like someone to contact you, please add your phone number here. (Optional)
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Oak Grove School District.
Report Abuse
Forms
