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Bullying Report Form
Respond to the questions that you can as accurately as possible. You must include your name and contact information in order to submit the form.
If you want to report a concern regarding an elementary-aged student, please contact the school's principal.
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* Indicates required question
Email
*
Your email
Your name
*
Your answer
Describe what happened/what is happening
Please be as detailed as possible.
Your answer
When did/does this bullying occur?
Your answer
Where does/did this happen?
Your answer
Who was committing the bullying?
If you don't know his/her name, please describe to the best of your ability.
Your answer
Who is the victim?
If you don't know his/her name, please describe to the best of your ability.
Your answer
Did anyone else witness the bullying?
If yes, please list.
Your answer
Was someone physically or emotionally hurt as a result of the bullying?
If yes, please explain.
Your answer
Was there damage to anyone's personal property?
If yes, please explain.
Your answer
Has the victim missed any school or made any changes to his/her daily routine as a result of the incident(s)?
Your answer
Have you told anyone about the bullying?
Example: parent, babysitter, brother/sister, teacher, family member, etc.
Your answer
Has this happened before?
If yes, please indicate number of times and details
Your answer
What is the victim's grade level?
*
Middle School (6-8)
High School (9-12)
What grade is the bullying victim in?
*
Choose
6
7
8
9
10
11
12
Are you willing to, or do you wish to, visit with an administrator regarding this incident?
*
Yes
No
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