Hope Bullying Report Form

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Please fill out this document to report any type of bullying that you may witness. This is an anonymous report, unless you choose to inform us your name. Please be reminded that bullying is an ongoing and deliberate misuse of power in relationships through repeated verbal, physical and/or social behaviour that intends to cause physical, social and/or psychological harm. It can involve an individual or a group misusing their power, or perceived power, over one or more persons who feel unable to stop it from happening.

Conflict is when there is a disagreement or argument in which both sides express their views.

Has this incident occured more than twice with the same person? *

Yes

Does the "bully" have more power over the victim? *

Yes

Your Name: Optional

Date: *

YYYY

Grade: *

Incident Location: *

Incident Date: *

YYYY

Incident Time: *

Time

Name of alleged bully. If name not known, any identifiable information: *

Describe the incident: *

Where there any witnesses? If yes, who? *

Yes

Other:

Other information, including previous incidents or threats:

Certification: This document will remain confidential. *

I certify that all statements made in the complaint are true and complete. I will also send copies of evidence, if applicable. Any intentional false statement of fact will subject me to appropriate discipline. I authorize school officials to disclose the information I provide only as necessary in pursuing the investigation.

Required

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