Challenger Middle School Bullying Report Form
Bullying is an act of aggressive behavior, which may be ongoing, in order to intentionally hurt another person. Bullying behavior may include:
 name calling
 intimidation
 threats
 public humiliation
 exclusion from activities
 unwanted touching
 physical abuse
 cyber bullying
Bullies may behave this way to be perceived as popular, tough, or to get attention. Bullying may seem harmless, but it can be very painful for the person targeted. Being the target of bullying can lead to depression and school performance and attendance issues. Bullies select their targets for many different reasons, such as race, ability, appearance, sexual orientation, gender and gender identity, or are just perceived to be different.
(Adapted from http://www.studentsspeakingout.org/)

If you believe that you have experienced bullying use this form to report the incident to Challenger Middle School Administration:
Date of Incident *
MM
/
DD
/
YYYY
Name of Person Reporting the Incident(s)
You may remain anonymous, but keep in mind it is difficult for us to investigate the incident if we do not know who is making the report.
Your answer
When and where the incident took place
Your answer
Name of the alleged victim(s) of the incident
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.
Your answer
Name of alleged offender(s) 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.
Your answer
Witnesses to the alleged bullying incident(s)
Please include witnesses, bystanders and/or anyone else who could provide more information about this report.
Your answer
Choose the area(s) that best describe what is being reported
Please check all that apply.
Please describe the incident(s) in as much detail as possible to assist with the investigation. The more specific and complete, the better. *
Your answer
As far as you know, what has been done to help stop the bullying?
Your answer
For an adult reporting an incident may we contact you directly?
Please provide a phone number or email address where you can be reached.
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of San Diego Unified School District. Report Abuse