Confidential Bullying Report Form

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I am a *

Student

Teacher

Staff member

Parent

Other adult

This happened to *

Choose one

A friend

A student

A stranger

My child

The victim is a student at

Barringer Road Elementary School

Fisher Elementary School

Jarvis Middle School

Central Valley Academy

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This bullying took place *

at Barringer Road Elementary School

at Fisher Elementary School

at Jarvis Middle School

at Central Valley Academy

on the school bus

Other:

This bullying was *

Physical (pushing, hitting, etc.)

Verbal (spoken out loud)

Electronic (cell phone, text, Facebook, etc.)

This happened *

During school

Outside of school

Did others witness the bullying? *

Yes

If others witnessed the bullying, what are their names?

Describe what took place.

Include the name of the person who was bullied and the name of the bully or bullies.

To fully investigate, a school DASA coordinator would like to speak with you. Please provide us with your full name.

This is voluntary. The DASA coordinator will not share your name with the bully or others who were involved.

How may we reach you?

Please provide us with a telephone number, email address, etc. We will reach out to students in school.

I fully believe the information I shared is true. *

I understand that knowingly making a false statement is against the law and is in violation of the Central Valley student code of conduct.

Yes, it is true to the best of my knowledge.

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