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Bullying Report Form
Please use the following form as one option to report instances of bullying. Please feel free to contact a building administrator if you have additional information that needs to be shared.
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* Required
Person making report (optional)
Your answer
Your relationship to victim
*
Parent
Grandparent
Guardian
Friend
Other
If reported to you by someone else, indicate who
Your answer
Date(s) of Incident
*
Your answer
Bullying Incident
Describe the bullying incident in as much details as possible.
*
Your answer
Type of bullying
*
Verbal
Non-Verbal (exclusion, eye-rolling)
Physical
Cyberbullying
Other:
Required
Who was Bullied? (Please list first and last names and grade level of all students, if reporting multiple students.)
*
Your answer
Who did the Bullying? (Please list first and last names and grade level of all students, if reporting multiple students.)
*
Your answer
Were there any bystanders? If yes, please list first and last name.
Your answer
Has this happened before?
*
No, this is the first time
Yes, this has happened before
This is an ongoing issue
Unknown
*Briefly describe the incident
*
Your answer
Any other information we need to know?
*
Your answer
By completing this form, you are verifying that your statements are true and accurate to the best of your knowledge.
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