South Jordan Middle Bullying Report Form
This is a confidential form that only South Jordan Middle Administration will see. We encourage you to complete the form with as much information as possible to help us address the issue and ensure students' safety here at our school. Together we can help keep SoJo a safe and positive educational environment.

Definition of Bullying
Bullying must have the 3 p's:
- Power: imbalance of power
- Purpose: person intends to hurt you
- Pattern or Persistence: person continues action over and over again

Name *
Only SoJo Administration will see your name. It is important so that we can come to you if we need additional information.
Your answer
What grade are you in? *
Your answer
Who is being bullied? *
Select who is the recipient of the harassment.
Name of the person being bullied.
First and last name, if possible, and their grade level. If the person filling out the form is the person being bullied, leave blank.
Your answer
Who is doing the bullying? *
Please give us the first and last name, if possible, and their grade level.
Your answer
What are they doing? *
Please describe in detail what actions others have done that might be considered bullying.
Your answer
Where is it happening? *
Describe the location in the school where the bullying is taking place. (ex. In the cafeteria by the vending machines)
Your answer
When is it happening? *
Describe when the bullying is happening. (ex. between 1st & 2nd Period)
Your answer
How long has it been happening? *
Describe the time frame of when the bullying has been happening. (ex. Every 2 or 3 days for the last month)
Your answer
Who has seen it happen?
List the names of anyone who has seen the bullying happen.
Your answer
Who have you told?
List the names of anyone who you have told about the bullying.
Your answer
Can we talk in person?
Please indicate if you would feel comfortable meeting with an Assistant Principal or Guidance Counselor to discuss the issue.
Contact Information
Please list a phone number or email address that we can use to contact you privately.
Your answer
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