Pinckneyville Intermediate School- Report Bullying
Use this form to report bullying you experienced or witnessed. Feel free to fill out as much or as little of this form as you feel comfortable with sharing. The more information you provide, the easier it will be to follow up on this behavior
What happened?
Please describe the bullying or harassment in as much detail as possible.
Your answer
Where did the bullying occur?
Was the bullying in the classroom, before school, in the hallways, at lunch, at home or online?Your answer
Your answer
What type of bullying happened?
Was the bullying or harassment over one of these issues?
Please indicate if the incident seemed to be motivated by one of these issues.
On what day did the bullying occur?
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DD
/
YYYY
At what time did the bullying occur?
Time
:
Was there physical injury?
Who was being bullied or harassed?
If you would like, let us know the names of the person(s) who were bullied or harassed. What grade and class are they in?
Your answer
Who did the bullying or harassment?
Please let us know the names of the person(s) doing the bullying or harassment. Were they students or staff? What grade and class are they in?
Your answer
Where there other witnesses?
Your answer
Is there any kind of proof?
Are you willing to share the proof?
(Photo, Email, Website, Social Media) Please paste a website link to proof if you can.
Your answer
Submit
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