Medway High School Anonymous Bullying Report Form
If you have information regarding bullying and would like to report this information, please fill out the following form to the best of your knowledge. For the purpose of this form, bullying is defined as a verbal, physical, written or electronic action or incident that is cruel and repetitive. Bullying is characterized by an imbalance of physical, psychological or emotional power.

Knowingly making a false report is a violation of school and state policy.

Please note that this form can be submitted anonymously.
Date
MM
/
DD
/
YYYY
Time
Time
:
Location (please check all that apply) *
Required
Please describe in as much detail as possible, what happened. *
Your answer
Do you know of any other witnesses? *
To your knowledge has there been a previous incident between these students? *
Are there any immediate safety concerns? *
Name of Target *
Your answer
Grade of Target
Is there any other information you would like us to know about the target?
Your answer
Name of Aggressor *
Your answer
Grade
Is there any other information you would like us to know about the aggressor?
Your answer
Name of Reporter (Optional)
Your answer
Phone Number (Optional)
Your answer
Email (Optional)
Your answer
Submit
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