Anonymous Bullying Report Form (Pequot Lakes Middle School)
Bullying is a serious issue and will not be tolerated at Pequot Lakes Middle School. Use this form to report bullying that occurred on school property, on the bus, was a part of a school event, on social media or through text message during the school day.
Bullying reports can be completed via this form, or through the use of an Incident Documentation Form (which can be found in the ML Office.)
I am a:
Phone Number (Optional)
Email Address (Optional)
Student who was harmed (please provide grade):
Student(s) who did harm (please include grade):
Date of Incident
Did you witness the incident?
Did any other students witness the incident?
Time of Incident
Location of Incident:
Nature of Bullying Being Reported:
Physical (Acts such as hitting, spitting, kicking, or damaging your/another student's possessions.)
Verbal (Saying mean or hurtful things or threatening you/another student.)
Social (Excluding you or a student from a group, telling peers not to talk to you or another student.)
Emotional (Spreading mean rumors or lies about someone.)
Cyber/Online (Occurs on website or social media, by cell phone, email or text message.)
Did the Bullying Include Mean Comments About You Or Other Students?
Race/Ethnicity or Perceived Race/Ethnicity
Sexual Orientation or Perceived Sexual Orientation
Gender or Gender Expression
Religious or Cultural Beliefs
Please provide the office with any other details about the incident that you feel are important.
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This form was created inside of Pequot Lakes Public Schools.