Student Bullying Report Form
Please complete this form, responding only to the questions that you feel comfortable answering and are able to accurately answer. You may choose to include your name at the bottom of the form or may submit it anonymously. Please note that the district's ability to investigate an anonymous complaint may be limited, and the District prohibits retaliation against anyone who files a bullying report.
Describe what happened/what is happening:
Your answer
When did it happen?
Date:
Your answer
Time:
Your answer
Where did it happen?
List specific school room or event, if applicable.
Your answer
Who was committing the bullying (if you don't know the bully's name(s) describe him/her)?
Your answer
Who was the victim of the bullying (if you don't know his/her name, describe him/her)?
Your answer
Did anyone else witness the bullying?
Please list any witnesses if possible.
Your answer
Were you or others physically hurt?
Please describe any physical injuries if any occurred.
Your answer
Was there damage to anyone's personal property?
Please describe any damage to anyone's personal property if any occurred.
Your answer
Have you or the victim(s) missed any school or made any changes to your daily routine as a result of the incident(s)?
Please describe any absences or changes to daily routines as a result of the incident(s).
Your answer
Have you told anyone about the bullying?
Please list any other family member or school staff that you told about the bullying
Your answer
Have you previously filed a bullying report (this information is used to determine if retaliation is occurring)?
Your name (optional):
Your answer
Your grade and age (optional):
Your answer
How can we contact you (phone, email, other)(optional):
Your answer
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