Douglass Anonymous Bullying Report Form v2
Douglass Elementary School is dedicated to ensuring that every student is a part of a safe and nurturing environment. We are interested in knowing about any bullying that may be occurring with or to our students. You may report this anonymously as a student, a parent, a teacher or as a concerned adult. This information is reviewed regularly during school hours. If you have added your contact information, please allow at least 24 hours for someone from the school to reply. If you responded anonymously, please add enough information for school staff to begin an investigation. If this is an emergency or something that needs immediate attention, please contact your student's Principal, Assistant Principal, or School Counselor directly.
1. Today's Date
2. Your name (optional)
3. Your telephone number and/or email address (optional)
4. Are you a:
5. Name of student (s) being bullied:
6. Name of the alleged offender.
7. Is the alleged offender older or younger than the person being bullied?
No, in an upper grade.
No, in a lower grade.
8. Date of the incident.
9. Name of any other person that could have seen the incident and could provide more information.
10. Where did the incident occur (check all that apply)
School sponsored event: athletic event,etc.
On the way to or from school
Social Media (Instagram, Snap Chat)
11. 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 (please also select which type from below)
Social Networks: Facebook, Twitter, Instagram, Snap Chat
12. Does this meet the definition of bullying? Definition: Intentionally aggressive behavior, repeated over time and involves an imbalance of power. If so, provide more information.
13. To your knowledge, has this been reported before?
14. If you answered "YES" to question #13, did someone respond within 24 hours? If not, did you follow up with a phone call to the school administration for assistance?
15. Is there any additional information that you would like to provide?
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