514.1 Bullying Report Form

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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.

First Name

It is more difficult to investigate anonymous reports.

Last Name

It is more difficult to investigate anonymous reports.

What is your e-mail address?

School Building *

Prairie Meadows

Prairie Woods

Middle School

High School

Date of Occurrence *

YYYY

Please provide the names and grades of persons involved in this report. *

Where did this incident take place? *

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. *

Please list all of the possible witnesses with knowledge of the incident.

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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