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.
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This form was created inside of Bricolage Academy. Report Abuse - Terms of Service - Additional Terms