MPS Bullying Report Form
When someone says or does something intentionally hurtful and they keep doing it even when you tell them to stop or show them that you’re upset, that’s BULLYING.
Please fill out the form for any incident that is bullying.
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* Required
Person Reporting the bullying (First and Last Name). If you want your response to be anonymous, please write "anonymous."
*
Your answer
When did the bullying happen?
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MM
/
DD
/
YYYY
Approximately what time?
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Time
:
AM
PM
Who was bullied? (First & Last name if possible)
*
Your answer
Who was doing the bullying? (First and Last name if possible)
*
Your answer
What type of bullying was taking place?
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Called mean names
Excluded (left out)
Stolen items
Threatened
Hit, kicked, punched
Told lied/spread rumors
Cyber-bullying (online activity on social media, e-mail, etc.
Racial/Offensive comments
Property Damage
Other:
Required
Where did the bullying take place?
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Hallway
Lunchroom
On the bus
Classroom
Playground
Bathroom
Going to/from school
Online
Other:
How many times has this happened?
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This is the first time
2-4 times
4-6 times
More than 6 times
Is there any other information you would like to share? Include names of witnesses.
Your answer
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