Bullying Report Form
We appreciate your effort and time, please fill in the following
Your Name (Optional)
School associated with incident:
East End Elementary
Edna Andrews Elementary
E. J. Hayes Elementary
South Creek Middle
South Creek High
I am a:
Parent / Guardian
Person being bullied
Have you reported this incident to anyone in authority?
The alleged bully is a:
Name of alleged bully.
Name of the person allegedly being bullied.
Location of the alleged incident.
On a bus
Physical: Hitting, kicking, or other physical aggression
Verbal: Teasing, name-calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad
Exclusion: starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without frineds
Cyber-bulling: Using a computer, cell phone, or other electronic device to engage in any previously mentioned bullying
Discription of what happened:
Did you witness what happened?
Please list other persons that witnessed what happened:
Your Contact Info (Optional)
Enter your Email
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