Elementary School Bullying Incident Form
We want to ensure the safety and well-being of all students at Blair Oaks R-II School District. We need your help to report when a child is unsafe or there is a potential safety issue at school. Sending in a false report takes time and resources away from helping those who really need it. This form can be used to report safety threats, including but not limited to, bullying, harassment, fights, drugs, alcohol or weapons at school. Responses may not be monitored continuously, so please call the appropriate building during school hours if you need immediate help (Elementary 573-634-2808, Middle School 573-634-2053, or High School 573-635-8514). Please refer to board policy (2655) for more information.
Name of student/victim: *
Your answer
Name of bully: *
Your answer
Name of witnesses (if any):
Your answer
Date and time of day that the incident happened: *
MM
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DD
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YYYY
Time
:
Where did the incident happen? *
Check all that apply.
Required
Which statement best describes what happened? *
Check all that apply.
Required
What other comments or statements do you have about the incident? *
Your answer
Has this incident been reported to anyone? *
Check all that apply.
Required
If yes, please include who the incident was reported to. *
Your answer
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