TMSA Bullying Report
Your Name: Optional
Are you a
Name of student being bullied
Name of alleged offender
Date of the incident
Where did the incident occur?
School Sponsored Event: Athletic Event, etc.
On the way to school or from school
In the morning (Auditorium/Cafeteria/Outside)
After school club/activity
Check the statement that BEST describes what happened
Hitting, kicking, shoving, spitting, hair pulling or throwing something
Getting another student to hit or harm the student(s)
Teasing, name-calling, making critical statements (racial comments, sexual orientation) or threatening a person or other means of communicating threats
Demeaning the victim and/or making jokes about the victim
Making rude and /or threatening gestures
Excluding or rejecting the student
Intimidating (bullying), extorting or exploiting
Spreading harmful rumors or gossip
Electronic Communication such as
Social Networks: Facebook, Twitter, MySpace
To your knowledge, has this been reported before?
Is there any additional information that you'd like to provide?
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