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Agua Dulce ISD Bullying Report
Bully Report
To submit a bully report, please fill out the form below. It will be submitted to the appropriate Administrator.
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* Indicates required question
“Knowing what's right doesn't mean much unless you do what's right.”
― Theodore Roosevelt
Are you reporting a Bully?
*
No
Yes
Other:
Date of Submission?
*
MM
/
DD
/
YYYY
Name of Person Reporting (Optional)
Your answer
I am a
*
Student
Parent/Guardian
Staff
Other:
Phone Number (Optional)
Your answer
Email (Optional)
Your answer
Student Who Was Harmed
*
Your answer
Grade Level
*
Pre K-5th
6th-12th
Other:
Student (s) Who Did Harm
*
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
Please Specify AM or PM
*
Time
:
AM
PM
Location
Your answer
Campus
*
High School
Elementary
Other:
Nature of Bullying
Physical (Acts such as hitting, spitting, kicking, or damaging your or another student's possessions)
Verbal (Saying mean or hurtful things or threatening you or 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 you or another student)
Cyber/Online (Occurs on website or social media, by cell phone, email or text message)
Other:
Clear selection
Did the bullying include mean comments about you or other students?
Physical Appearance
Gender or Gender Expression
Academic Performance
Race/Ethnicity or Perceived Race/Ethnicity
Religious or Cultural Beliefs
Sexual Orientation or Perceived Sexual Orientation
Other:
Clear selection
Did Physical Injury result for this incident?
No
Yes, but no medical attention was not required
Yes, and medical attention was required
Clear selection
Please give any other details about this incident you feel are important.
Your answer
Did you witness this event?
No
Yes
Other:
Clear selection
Who else saw this happen? (Including adults, if any): Enter names of witnesses
Your answer
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