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514.1 Bullying Report Form
Please fill out this form in it's entirety. You may choose to remain anonymous. However, that may limit some of our ability to investigate the situation. We encourage you to do what you feel is right.
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* Indicates required question
First Name
Your answer
Last Name
Your answer
What is your e-mail address?
Your answer
School Building
*
Prairie Meadows
Prairie Woods
Middle School
High School
Date of Occurrence
*
MM
/
DD
/
YYYY
Please provide the names and grades of persons involved in this report.
*
Your answer
Where did this incident take place?
*
Your answer
What was the nature of the incident being reported (check all that apply)?
*
Physical (hitting, spitting, kicking, or damaging your or another students property)
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 rumors or lies about someone)
Cyber/Online (occurs on website, social media, cell phone, e-mail, and/or text message)
Other:
Required
Please select any of the following in which the bullying may have been related to.
Physical Appearance
Academic Performance
Race/Ethnicity
Sexual Orientation
Gender or Gender Expression
Religious or Cultural Beliefs
Please describe the incident in detail.
*
Your answer
Please list all of the possible witnesses with knowledge of the incident.
Your answer
By checking the box below, you affirm that all information shared within this form is accurate and true.
*
The information in this form is accurate and true.
Required
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