Bullying Form
BULLYING INCIDENTS CAN BE REPORTED ANONYMOUSLY.
Name of student target (victim) *
Your answer
Where Does he/she attend school? *
Required
Has the appropriate teacher/coach/bus driver been contacted? *
If yes, please provide the name(s) of who you contacted:
Your answer
Name(s) of alleged bully(ies) (if known):
Your answer
On what date(s) did the incident happen? * *
MM
/
DD
/
YYYY
Where did the incident happen? Please choose all that apply: *
Required
Please select the statement(s) the best describe what happened. Please choose all that apply: *
Required
What did the alleged bully(ies) say or do? *
Your answer
Why did the harassment or intimidation (bullying) occur? *
Your answer
Were there any witnesses? *
Did a physical injury result from this incident?
If yes, please describe:
Your answer
Was the victim absent from school as a result of the incident? *
If yes, please describe:1
Your answer
Is there any additional information you would like to provide?
Your answer
Name of person reporting (optional)
Your answer
Today's Date: *
MM
/
DD
/
YYYY
Email (optional):
Your answer
Phone Number (optional):
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Circle USD 375. Report Abuse - Terms of Service - Additional Terms