Bullying Reporting Form

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Bullying is hurtful and we do not tolerate it at our school. It can be hard to tell an adult about bullying. Some kids worry that they will be called a “tattletale.” Telling is not being a tattletale. Telling, which adults call reporting, is a good thing to do. If you or another student has been bullied or hurt, or you are worried that you or another student could be bullied or hurt in the future, tell a teacher or another adult at your school. The adults will help you.

You can fill out this form to tell school staff about bullying that has happened this school year. This information will be automatically sent to the school principal to investigate.

We know it can be scary to tell or “report” bullying, so you do not have to include your name on this form. However, a teacher or the principal may want to ask more questions about this, so including your name will help them look into the problem.

Your Name:

Are you a parent/guardian or student?

Parent/Guardian

Student

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Student(s) that was harmed:

Student(s) that caused the harm:

When did it happen?

YYYY

Where did it happen?

What kind of bullying happened?

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 another student from a group, telling other kids 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:

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Please tell us what happened:

Did you see/hear what happened?

Yes

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What else saw/heard what happened?

Was there a staff member nearby when this happened? If so, who?

Submit

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