Tuloso-Midway Middle School Bullying Incident Report Form

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Please help us provide a safe learning environment for you and your peers by filling out the Bullying Incident Report form. We ask that you please provide us with some information if you or someone you know is a victim of bullying. You will not be asked to provide your name. You will simply be asked to provide some details pertaining to the incident. The information you submit will be sent to the campus administrator.

Today's Date: *

YYYY

Date of the Incident: *

YYYY

Where did the incident take place? *

On the way to school

In the classroom

In the hallway

In the cafeteria

On the bus

At the bus stop

In the restroom

In the locker room

In the parking lot

On the internet

At an after school program

Other:

If the incident occurred at school, which campus?

Who was the person(s) engaged in bullying? What grade(s) are they in? *

Who was the person(s) being bullied? What grade are they in? (All names will be kept confidential) *

What type of bullying occurred? *

Please explain the incident

Provide as much detail as possible

Submit

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