Problem Solving Form
This form may be completed by any parent, student, friend, etc...
Your email address and name are required fields, however, if you wish to remain anonymous, please fill in the appropriate response on prompt #3. The administration will be the only ones to see this information contained in this report. Please refer to our Discipline Policy for more information regarding the handling of bullying/harassment for more information about the steps the school will take when this form is submitted.
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* Required
Email
*
Your email
Name
*
Your answer
Reported to the school by (check all that apply)
Teacher
Victim/Target
Student
Parent
Bystander
Anonymous
Other:
Date of incident (mm/dd/yy)
*
Your answer
Location of Incident (check all that apply)
Hallway
Restroom
Classroom
Gym
Lunch Room
Playground
Parking Lot
To/From School
After School Program
School Sponsored Event
Text/Phone/Internet/Social Media
Other:
Name of Person(s) harmed:
Your answer
Name of Person(s) causing the harm:
Your answer
Name(s) of witnesses
Your answer
Type of interaction
Verbal
Relational
Physical
If physical, did it result in injury?
Yes
No
Clear selection
If yes, was the injury reported to the school?
Yes
No
Clear selection
Problem behaviors (check all that apply)
Shoved/pushed
Excluded
Hit, Kicked, Punched
Taunting/ridiculing
Threatened
Writing/Graffiti
Stole/Damaged Possessions
Told Lies or False Rumors
Staring/Leering
Intimidation/Extortion
Demeaning Comments
Inappropriate touching
Cyber-bullying: text, website email, other...
Racial, Sexual, Religious, or Disability
Other:
Describe the incident
Your answer
Physical Evidence?
Notes
Email
Graffiti
Vido/audio
Website
Other:
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