Bullying and Harrassment Form
Name of the student (s) who was (were) bullied.
Name of the student (s) who did the bullying.
Who are you? (You may remain anonymous)
Food Service Staff
Your name. You may remain anonymous. If you leave your name we might contact you to get further information.
Check which best describes the alleged harrassment, intimidation, and/or bullying behavior the target was subjected to:
Physical Bullying (pushing, shoving, hitting, threats, vandalism, theft, etc.)
Emotional Bullying (name calling, insults, teasing about appearance, exclusion, public humiliation, etc.)
Cyber-Bullying (texting/messaging threats, inappropriate web posts, derogatory emails, etc.)
Have there been multiple incidents?
Where did the incident occur?
Social Media (Facebook, Twitter, etc.)
Phone or text
Expain with as much detail as possible what happened. (Include witnesses and locations)
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This form was created inside of Pontiac-William Holliday School District #105.
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