Roosevelt School Bullying Report Form
Please complete the questions you are comfortable answering or are able to accurately answer. You may choose to include your name of the form or submit anonymously. Please note that the District's ability to investigate an anonymous complaint may be limited, and the District prohibits retaliation against anyone who files a bullying report. Click submit at the bottom of the page when you have completed the form.
If you wish, you may request a paper copy of this form by contacting the school. A completed form can be returned to the office.
What day did the incident occur?
Describe what time(s) of day the incident happen (before school, morning, lunch, afternoon, after school...etc.)
Describe where the incident happen (classroom, hallway, locker room, bus..etc.)
Described what happened in as much detail as possible such as the name of the person(s) bullying, the name of the person(s) being bullied, and any witnesses.
Did the incident result in a physical injury? If yes, please include the name(s) of person(s) that caused the injury, the person(s) injured, and any witnesses?
Did the incident result in property damage? If yes, please describe the name(s) of person(s) who caused the property damage, the person(s) that had their property damaged, and any witnesses.
Has the person(s) being bullied, injured or having damaged property missed school or made changes to their daily routine? If yes, please describe.
Have you told anyone about the bullying, injury, or damaged property? If yes, who did you tell and when?
What is your name, grade/age, and how can you be contacted? (optional)
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