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 an alleged 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 directly to a Muirlands' School Counselor or Administrator.
Intentional false reporting can lead to disciplinary action. Thank you for helping keep Muirlands Middle School Bully-free and safe!
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Date of Incident
Please put an X in the text area to continue.
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 and, if appropriate, confidentiality of the reporting individual(s). Please note that anonymous reports may be more difficult to investigate. Your courage to be an upstander is appreciated!
When did the incident(s) happen (e.g. period, time of day, etc.)?
The more specific the better!
Where did the incident(s) happen?
The more specific the better!
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 or details that would assist an Administrator in making a determination of who the alleged Victim(s) is/are. You can enter more than one name if appropriate.
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 or details that would assist an Administrator in making a determination. You can enter more than one name if appropriate.
Witnesses to the alleged bullying incident(s)
Please include witnesses, bystanders and/or anyone else who could provide more information about this report.
Choose the area(s) that best describe what is being reported
Please check all that apply.
Verbal, including teasing
Online/Social Media (e.g. Facebook, Instagram, Snapchat)
Phone, including text messages
Intimidation or threats
Related to race
Related to disability
Please describe the incident(s) in as much detail as possible to assist with the investigation. The more specific and complete, the better!
As far as you know, what, if anything, has been done to help stop the bullying?
For an Adult reporting an incident, if decided, may we contact you directly?
Please provide a phone number or email address where you can be reached.
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This form was created inside of San Diego Unified School District.