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Savage Public School Student Bullying Report Form
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* Required
Email
*
Your email
When did it happen?
*
MM
/
DD
/
YYYY
Describe what happened/what is happening:
*
Your answer
When did it happen?
*
Time
:
AM
PM
When did it happen?
*
Before School
During School
After School
Unsure
Who was committing the bullying (if you don't know the bully's name(s) please describe him/her)?
*
Your answer
Who was the victim of the bullying (if you do not know his/her name, please describe him/her)?
*
Your answer
Did anyone else witness the bullying? (If yes, you will be asked below to list them.)
*
Yes
No
Please list others that witnessed the bullying.
*
Your answer
Were you or others physically hurt?
*
Yes
No
Unsure
If others were hurt, please explain.
Your answer
Was there damage to anyone's personal property?
*
Yes
No
Unsure
If there were damages to personal property, please explain.
Your answer
Have you or the victim miss any school or make any changes to your daily routine as a result of the incidents?
*
Yes
NO
Unsure
If yes, please explain.
Your answer
Have you told anyone about the bullying?
*
Parent
Babysitter
Brother/Sister
Other Family Member
Teacher
School Staff
Other:
Have you previously filed a bullying report? (This information is used to determine if retaliation is occurring. )
*
Yes
No
Your name
*
Your answer
Your grade and age
Your answer
How can we contact you? (e-mail, telephone, and/or other) Please provide the information below in which you would like us to contact you.
*
Your answer
Send me a copy of my responses.
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