Saint Ignatius School Bullying Report Form
Instructions: Please complete the entire form, responding only to the questions that you are comfortable answering and are able to accurately answer. You may choose to include your name at the bottom of the form or may submit it anonymously. We urge you to put your name at the bottom since we have limited ability to act on anonymous reports. The school prohibits any type of retaliation against anyone who files a report. If you'd like to discuss this issue further, please reach out to either Mrs. Farkas (Grades K-3), Mrs. Moeller (Grades K-3), Ms. Van Berkel (Grades 4-8), or Ms. Beer (Grades 4-8).
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Describe what has been happening.  Please give specific examples including how often it occurs.
When has it been happening?
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Who is committing the bullying?  (If you do not know the name, please tell us what grade and describe the person as much as possible.)
Who is the victim of the bullying? (If you do not know the name, please tell us what grade and describe the person as much as possible.)
Has anyone else witnessed the bullying?  (If yes, please list their names)
Have you or others been physically hurt by the bully?  Please explain.
Has there been damage to anyone's personal property?  Please explain.
Have you or the victim missed any school or made changes to your daily routine as a result of the bullying?  Please explain.
Have you told anyone about the bullying?  Please name the teacher, school staff member, parent, other family member, or other adult.)
Have you previously filed a bullying report? (This is used to determine if retaliation is occurring.)
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Do you feel safe at school? *
Did you complete the form by yourself?
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If someone helped you to complete the form, please identify the person who helped you.
Please add any further information you would like us to know.
Your Name
Grade
What is today's date? *
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Reports can be made anonymously, but we can not promise that any action will be able to be taken on an anonymous report.
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