Report Form for Bullying and School Violence
* Required
Rogers Elementary School
To be completed by the bullying target, witness, or person with information about an incident of bullying or school violence. This form will be submitted to the assistant principal.
Name
Your answer
Student
Parent
Staff
Other
Indicate if you prefer to remain anonymous.
Choose
Yes
No
Are you the target of the bullying or school violence that you are reporting?
Choose
Yes
No
Date of incident:
MM
/
DD
/
YYYY
Time of incident:
Time
:
AM
PM
Person(s) being reported as targets of bullying or school violence:
Please indicate if the person(s) is a student, staff member, or other.
Your answer
Person(s) being reported as aggressors engaged in bullying or school violence:
Please indicate if the person(s) is a student, staff member, or other.
Your answer
Person(s) who witnessed the bullying or school violence:
Please indicate if the person(s) is a student, staff member, or other.
Your answer
Was the incident based on any of these characteristics?
Check all that apply.
Race
Color
Nationality
Sex
Sexual orientation
Gender identity
Gender-related identity
Gender-related expression
Ancestry
Mental disability
Order of protection status
Homeless status
Marital status
Parental status
Pregnancy
Associated with person/group with one or more of the above actual or perceived characteristics
Other
I do not know
Student(s) were targeted for bullying in the following place(s):
Check all that apply.
Classroom
Locker Room
Hallway
Extra-curricular activity
Cafeteria
Bus
Restroom
Bus stop
Gym
School or related activity or event
Other
Please tell us about the incident in your own words. Use as much detail as possible - what time did the incident(s) take place, who witnessed it, what was said, what types of interactions occurred (physical, written, social, electronic, etc.)
Your answer
*
The above information is true and accurate to the best of my knowledge.
Required
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