Bullying Report
All data reported on this form goes directly to a District administrator.
* Required
Email Address
*
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
Approximate Time of Incident
*
Time
:
AM
PM
During this incident, I was...
*
The person being bullied
A bystander/witness to the bullying
Other:
Who was the person(s) engaged in the bullying incident?
Your answer
What school does the person(s) engaged in the bullying attend?
*
Arnold
King
Landell
Luther
Morris
Vessels
Who was being bullied?
*
Your answer
What school does the person being bullied attend?
*
Arnold
King
Landell
Luther
Morris
Vessels
What type of bullying occurred?
*
Physical
Emotional/Social
Damage to Property
Online
Other:
Required
Where did the incident take place?
*
Bus
Cafeteria
Classroom
Playground
Restroom
School Sponsored Event
Social Media/Online
Other:
Other Location Details
Please explain the specific location details such as which classroom, which social media site, what restroom, etc.
Your answer
Describe what happened with as many details as possible.
*
Your answer
Person Reporting the Incident
Optional (Please use your full name)
Your answer
May we contact you for more information on this incident?
*
Yes
No
If you indicated "yes" to the previous question, please provide your phone number should the responding administrator need to contact you:
Your answer
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