Student Bullying Report
Bullying is negative acts that is done on purpose and involves an imbalance of power. Bullying is not a one time action, but it is repeated over time.
* Required
First and last name of victim (who is getting bullied)
*
Your answer
Grade of victim
*
6th
7th
8th
First and last name of the alleged bully (who is alleged offender)
*
Your answer
Grade of alleged bully
*
6th
7th
8th
not a student
Name of any witnesses (who saw this happen to you)
*
Your answer
Who is reporting this information? (Who is completing this form)
*
Self
Friend
Parent
School Staff
Bystander
Dates of incidents (What dates did it happen?)
*
Your answer
Where did the incident occur (check all that apply)
*
in class
at lunch
at recess
at home
in hallway
in the bathroom
at school event
Other:
Which statement(s) best describe what happened? (check all that apply)
*
Bullying, harassment, or intimidation involving physical aggression
Teasing or name-calling
threatening and/or verbal intimidation
Rude or threatening gestures
Spreading harmful rumors/ gossip
Cyber bullying (ex. Facebook, Twitter, Instagram, Vine, YouTube)
Electronic Communication (ex. GMail, text messages, KiK, Snapchat, online chats)
Sexual Harassment
Property damage or stolen property
Other:
Please provide details about the situation
*
Your answer
How many times has the incident occurred or the alleged bully done something to the victim?
*
Your answer
Have you told anyone about the bullying? (check all that apply)
*
Parent
Teacher
Family member
Friend
Other school staff member
I haven't told anyone
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