Bullying Reporting Form

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Name of Individual Being Bullied *

Contact Information (Optional)

I am a *

Student

School Employee

Parent/Gurdian

Person being bullied

Concerned Citizen

Other:

Have you reported this incident to anyone in authority? *

Yes

Name of target(s): *

Name of student(s) bullying: *

Name of witnesses/bystanders: *

Date(s) of Incident: Since she showed up *

Location of the alleged incident. (Check all that apply)
*

Hallway

Restroom

Classroom

Gym

Commons

Auditorium

Locker Room

Bus Stop

To/From School

School Sponsored Event

Text/Phone/Internet/Social Media

Other:

Required

What type of bullying are you reporting? (Check all that apply) *

Physical: Hitting, kicking, or other physical aggression

Verbal: Teasing, name-calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad

Relational: starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without frineds

Cyber-bulling: Using a computer, cell phone, or other electronic device to engage in any previously mentioned bullying

Required

Description of what happened.
*

Additional Comments:

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