WCHS Bullying Report Form
Washington Community High School is committed to creating a safe, supportive, and positive environment for students to obtain an education. School incidents involving bullying are taken very seriously at WCHS. When these incidents are reported, support services can be provided to all students involved.

As stated in the WCHS Student Handbook, bullying is defined as physical or verbal conduct, by one or more students, which serves to harass, demean, humiliate, abuse, victimize, deny, or exclude one or more students from the pursuit of participation in, and/or enjoyment of any program or activity, including academic and nonacademic classes and extracurricular activities, offered or sponsored by the School District or in any facility operated by the Board of Education.

This form has been created to help provide a safe means of reporting an incident of bullying to school personnel. It is designed to remain anonymous, and it is encouraged that bystanders of bullying incidents report their observations so appropriate action can be taken. Victims of bullying and witnesses are also encouraged to use this form, as well as, reporting the incident directly to the staff at WCHS.

Thank you for taking the time to complete this form. WCHS appreciates your help in maintaining a safe environment for our students.

Your Name (Optional)
Your answer
Date
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You are a: *
Indicate here if you prefer to remain anonymous.
Are you the target of the bullying or school violence that you are reporting? *
Date of Incident *
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DD
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Time of Incident
Your answer
Person being bullied? *
Your answer
Name of offender? *
Your answer
Bullying witness *
Did you witness the bullying?
Other witnesses
Your answer
How long has the bullying been going on? *
Please report whether this is the first time or if it has been going on for a longer period of time (days, weeks, etc.)
Your answer
Was the incident based on any of these characteristics? (Check all that apply.) *
Required
If you answered the previous question as "Other", please explain.
Your answer
Student(s) were targeted for bullying in the following way(s): (Check all that apply): *
Required
If you answered the previous question as "Other", please explain.
Your answer
Student(s) were targeted for bullying in the following place(s): (Check all that apply.) *
Required
If you answered the previous question as "Other", please explain.
Your answer
Please tell us about the incident in your own words. Use as much detail as possible - what time did the incident(s) take place, who witnessed it, what was said, what types of interactions occurred (physical, written, social, electronic, etc.) *
Your answer
The above information is true and accurate to the best of my knowledge. *
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