Booker T. Washington Learning Center Anonymous Bullying Report Form v2
Booker T. Washington Learning Center is dedicated to ensuring that every student is a part of a safe and nurturing environment. We are interested in knowing about any bullying that may be occurring with or to our students. You may report this anonymously as a student, a parent, a teacher or as a concerned adult. This information is reviewed regularly during school hours. If you have added your contact information, please allow at least 24 hours for someone from the school to reply. If you responded anonymously, please add enough information for school staff to begin an investigation. If this is an emergency or something that needs immediate attention, please contact your student's Principal or School Counselor directly.
Email address *
1. Today's Date *
Your answer
2. Your name (optional)
Your answer
3. Your telephone number and/or email address (optional)
Your answer
4. Are you a: *
5. Name of student being bullied. *
Your answer
6. Name of alleged offender.
Your answer
7. Is the alleged offender older or younger than the person being bullied? *
8. Date of the incident *
MM
/
DD
/
YYYY
9. Name of any other person that could have seen the incident and could provide more information.
Your answer
10. Where did the incident occur (check all that apply) *
Required
11. Check the statement that BEST describes what happened: *
Required
12. Does this meet the definition of bullying? Definition: Intentionally aggressive behavior, repeated over time and involves an imbalance of power. If so, provide more information. *
Your answer
13. To your knowledge, has this been reported before? *
14. To your knowledge, has this type of incident happened with this student before? *
15. Is there any additional information that you would like to provide? *
Your answer
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