Pine Island Bully Reporting Form Grades K-4
Before filing an official bully report, we would like to make sure that what you are reporting is bullying and not another type of incident. Please complete the pre-questions before filing the report. In order to be bullying, the incident needs to fall under all 3 of the following criteria.
* Required
Pre-Question 1: Have incidents occurred more than once? Please list approximate dates of the multiple incidents.
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Your answer
Pre-Question 2: Is there an imbalance of power? Please explain the imbalance.
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Your answer
Pre-Question 3: Have the incidents affected your life at school? Please explain how your school life has changed since the incidents began.
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Your answer
Reporter name:
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Your answer
You are reporting as:
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Teacher/Staff
Student
Parent
Other:
Date of incident:
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MM
/
DD
/
YYYY
Name of student(s) to whom bullying was directed:
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Your answer
Name of student(s) who engaged in bullying:
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Your answer
Location of incident:
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Your answer
Witnesses:
Your answer
Description of the incident:
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Your answer
Check any that apply if the bullying was directed to another student based on the student's actual or perceived:
race
ethnicity
color
creed
religion
national origin
immigration status
sex
marital status
family status
socioeconomic status
physical appearance
sexual orientation
gender identity or expression
academic status
disability
age
Other:
Did the bullying occur through electronic communication? If so, explain the type or form of communication.
Your answer
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