Savage Public School Student Bulling Report Form
Email address *
Describe what happened/what is happening: *
Your answer
When did it happen? *
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DD
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YYYY
When did it happen? *
Time
:
When did it happen? *
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.) *
Please list others that witnessed the bullying. *
Your answer
Were you or others physically hurt? *
If others were hurt, please explain.
Your answer
Was there damage to anyone's personal property? *
If there were damages to personal property, please explain.
Your answer
Have you or the victim missed any school or made any changes to your daily routine as a result of the incidents? *
If yes, please explain.
Your answer
Have you told anyone about the bullying? *
Have you previously filed a bullying report? (This information is used to determine if retaliation is occurring. ) *
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
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