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Bullying Report Form
Please fill out this form to report an incident
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* Indicates required question
Name (optional)
Your answer
Date
*
MM
/
DD
/
YYYY
I am (choose one
*
Student
Parent/Guardian
Staff Member
Other
Student's Name Who Was Harmed
*
Your answer
Student's Name Who Did Harm
*
Your answer
When did it happen
*
Your answer
Where did it happen
*
Your answer
Did the bullying include mean comments about you or your friends? What were the mean comments about?
*
Size, weight or how you look (appearance)
How well you do in school (academics/athletics)
Your religion or beliefs
Gender
Skin Color
Other things
Required
What kind of bullying happened? Was it:
*
Physical (acts such as hitting, spitting, kicking, or damaging one's possessions
Verbal (saying mean or hurtful things or threatening you or another student
Social (excluding you or another student from a group, telling other kids not to talk to you
Emotional (spreading mean rumors or lies about you or another student
Cyber/Online (occurs on website or social media, by cell phone, email or text messages
Other
Required
Please explain to us what happened:
Did you see the event happen?
Was an adult nearby?
Did anyone else see what happened?
Any other details you feel necessary to add
*
Your answer
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