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Bullying Report Form
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* Indicates required question
Your Name (Optional)
Your answer
School associated with incident:
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Choose
East End Elementary
Edna Andrews Elementary
E. J. Hayes Elementary
Jamesville Elementary
Rodgers Elementary
Williamston Primary
Riverside Middle
South Creek Middle
Riverside High
South Creek High
I am a:
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Student
School Employee
Parent / Guardian
Person being bullied
Concerned Citizen
Friend
Other:
Have you reported this incident to anyone in authority?
*
Yes
No
Required
The alleged bully is a:
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Student
School Employee
Name of alleged bully.
*
Enter name
Your answer
Name of the person allegedly being bullied.
*
Enter name
Your answer
Location of the alleged incident.
*
At School
On a bus
Athletic Event
Other:
What happened?
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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
Other:
Required
Discription of what happened:
*
Your answer
Did you witness what happened?
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Yes
No
Please list other persons that witnessed what happened:
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Additional Comments:
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Your Contact Info (Optional)
Enter your Email
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