Bullying Report Form- Parent and Guardian
This form is for reporting instances of bullying to relevant Bricolage staff. We take bullying behavior very seriously and will intervene in a timely manner. Please keep in mind that we define bullying as "repeated." Therefore, this form asks for 4 incidents of bullying behavior.
Email address *
What is your name? (The reporter) *
Your answer
What is the name of the student being bullied? *
Your answer
What is the name of the student suspected of bullying? *
Your answer
At Bricolage, we have taught students that bullying is repeated, on purpose, mean/hurtful, and hard to defend against. We define repeated as 4 instances at our school. We have also taught four distinct steps to take in order to protect yourself from bullying behaviors. Are you familiar with these steps? *
Please describe the first incidence of bullying. *
Your answer
Please describe what the child experiencing the bullying did in response. Please be detailed. *
Your answer
What other students witnessed the first incident? *
Your answer
Please describe the second incidence of bullying. *
Your answer
Please describe what the child experiencing bullying did in response. Please be detailed. *
Your answer
What other students witnessed the second incident? *
Your answer
Please describe the third incidence of bullying. *
Your answer
Please describe what the student experiencing bullying did in response. Please be detailed. *
Your answer
What other students witnessed the third incident? *
Your answer
Please describe the fourth incidence of bullying. *
Your answer
Please describe what the student experiencing bullying did in response. Please be detailed. *
Your answer
What other students witnessed the fourth incident? *
Your answer
Please briefly describe how the student experiencing bullying is being affected emotionally, academically, or socially. *
Your answer
Have you spoken to any staff members (including the student's teacher) about the incidents? What was the result of the conversation? *
Your answer
Is there any other relevant information to this case? *
Your answer
Please leave your contact phone number and email with preferred method of contact and times to contact. *
Your answer
A copy of your responses will be emailed to the address you provided.
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