Muirlands Safe to Speak Bullying Report Form
Bullying is unwanted, aggressive behavior among peers that involves a real or perceived power imbalance. Bullying is both severe and pervasive aggressive behavior. Bullying behaviors happen more than once or have the potential to happen more than once. That is, the behavior is repeated, or has the potential to be repeated, over time. This form should be used to report a possible incident of bullying as defined in the San Diego Unified District's Policy prohibiting bullying and harassment. Any student/adult can report bullying or harassment by talking to an Administrator, completing this online form, or completing a paper form available in the Muirlands' Office and returning it to a Counselor or Administrator. If you believe that a student is in IMMEDIATE danger, please immediately report the incident to a Muirlands School Counselor or Administrator. Thank you for helping keep Muirlands Middle School Bully-free! Intentional false reporting can lead to disciplinary action.
Date of Incident
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Name of person reporting incident(s)
If you would like to remain anonymous, you may leave this field blank. School Administration is experienced with protecting the identity of the reporting individual. Please note that anonymous reports may be more difficult to investigate. Your courage is appreciated.
Your answer
When did the incident(s) happen (period, time of day, etc.)? The more specific the better.
The more specific the better.
Your answer
Where did the incident(s) happen?
The more specific the better.
Your answer
Name of alleged Victim(s)- this is the person(s) who was harmed/injured by the action/incident
If you do not know the name(s), please provide a description.
Your answer
Name of alleged Offender(s) who you witnessed (or is/are being reported) as doing the bullying
If you do not know the name, please provide a description. You can enter more than one name if appropriate.
Your answer
Witnesses to the alleged bullying incident(s)
Please include bystanders and anyone who could provide more information
Your answer
Choose the statement(s) that best describe what happened
Please check all that apply.
Required
Please describe the incident(s) in as much detail as possible to assist with the investigation
Your answer
For an Adult reporting an incident, may we contact you about this incident?
Please provide a phone number or email address where we can reach you.
Your answer
As far as you know, what, if anything, has been done to help stop the bullying?
Your answer
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