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.
Sign in to Google to save your progress. Learn more
Pre-Question 1: Have incidents occurred more than once? Please list approximate dates of the multiple incidents. *
Pre-Question 2: Is there an imbalance of power? Please explain the imbalance. *
Pre-Question 3: Have the incidents affected your life at school? Please explain how your school life has changed since the incidents began. *
Reporter name: *
You are reporting as: *
Date of incident: *
MM
/
DD
/
YYYY
Name of student(s) to whom bullying was directed: *
Name of student(s) who engaged in bullying: *
Location of incident: *
Witnesses:
Description of the incident: *
Check any that apply if the bullying was directed to another student based on the student's actual or perceived:
Did the bullying occur through electronic communication?  If so, explain the type or form of communication.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pine Island Public Schools ISD 255. Report Abuse
Google Forms