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 *
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2. Your name (optional)
Your answer
3. Your telephone number and/or email address (optional)
Your answer
4. Are you a: *
5. Name of student (s) being bullied: *
Your answer
6. Name of the alleged offender. *
Your answer
7. Is the alleged offender older or younger than the person being bullied? *
8. Date of the incident. *
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9. Name of any other person that could have seen the incident and could provide more information.
Your answer
10. Where did the incident occur (check all that apply) *
Required
11. Check the statement that BEST describes what happened: *
Required
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. *
Your answer
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?
Your answer
15. Is there any additional information that you would like to provide? *
Your answer
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