Bullying Report Form
Bullying/Harassment is characterized by the following behaviors:
"Physical intimidation or assault; extortion; oral or written threats; teasing; “put downs;” name calling; threatening looks; gestures, or actions; cruel rumors; false accusations and social isolation are examples of bullying."

Use the following form to report an observed incident of bullying. All submitted reports are sent directly to the Saint Rosalia Academy Principal and the Student Support Team.

Thank you for demonstrating the Saint Rosalia Academy expectations: I Respect Myself, I Respect Others, I Respect My School
My name is: *
Your answer
Date(s) of Incident: *
Your answer
Type of Bullying? *
I observed Bullying/Harassment *
Time of incident
The Bullying/Harassment occurred *
Where did this happen?
The Bullying/Harassment was initiated by: *
Enter the person's name
Your answer
Who was Bullied? *
(Please list first and last names and grade level of all students, if reporting multiple students.)
Your answer
The Bullying/Harassment that I observed was: *
Provide a description of the bullying/harassment incident
Your answer
Has this happened before? *
I have already spoken with the following people regarding this Bullying/Harassment incident:
Check all that apply
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