Elementary Student Bullying Form
Please complete this form.  Responding only to the questions that you feel 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.  Please note that the District's ability to investigate an anonymous complaint may be limited, and the District prohibits retaliation against anyone who file a bullying report.
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Describe what happened/what is happening.
When did it happen?
Check all that apply
What was the time and date that this happened?
Where did it happen?
Check all that apply
Who was committing the bullying (if you are unsure of the bully's name(s) describe him/her?
Who was the victim of the bullying (if you are unsure of his/her name, describe him/her?
Did anyone else witness the bullying?
Clear selection
(If yes, please list)
Were you or others physically hurt?
(If yes, please explain)
Clear selection
(Explain)
Was there damage to anyone's personal property?
(If yes, please explain)
Clear selection
(Explain)
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)?
(If yes, please explain)
Clear selection
(Explain)
Have you told anyone about the bullying?
Check all that apply
Have you previously filed a bullying report (this information is used to determine if retaliation is occurring)?
Clear selection
Name (Optional)
Your grade and age (Optional)
How can we contact you (Phone, Email, Other)?
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