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Gustine ISD Bullying Reporting Form
This form is to be used to report potential incidents of bullying. The purpose of this form is to alert Gustine ISD Administrators of possible inappropriate behavior so they can conduct a thorough investigation. Providing more detailed information will lead to a more thorough the investigation.
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* Indicates required question
Date
*
MM
/
DD
/
YYYY
Person making report: (This is optional, however by giving us your name it will make a thorough investigation easier.)
Your answer
I am a:
*
I Am a Current Gustine ISD Student
I Am the Parent/Guardian of a Current Gustine ISD Student
I Am a Member of the Gustine ISD Staff
Other:
Day Time Phone Number (optional)
Your answer
Address (optional)
Your answer
Email Address (optional)
Your answer
Person or Persons That Are The Target of Inappropriate Behavior (Please provide first and last names.)
*
Your answer
Person or Persons That Are Behaving Inappropriately (Please provide first and last names.)
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
*
Time
:
AM
PM
Location Where Incident Occurred (Be as specific as possible.)
*
Your answer
Type of Harassment
*
Verbal
Written
Physical
Electronic (email, Facebook posts, Twitter posts, Snapchat posts,...)
Racial
Sexual
Religious
Disability
Other:
Witnesses (List people who saw or heard the incident or that have relevant information about the incident. Please tell us if the witness is a parent, staff member, student or community member.)
*
Your answer
Description of Incident
*
Name Calling
Stalking
Inappropriate Gesturing
Damaging Property
Writing/Graffiti
Threatening
Taunting/Ridiculing
Inappropriate Touching
Spitting
Demeaning Comments
Cyber Bullying
Flashing a Weapon
Shoving/Pushing
Hitting/Kicking
Intimidation/Extortion
Other:
Describe the incident in detail, including the name of the person or persons involved, what was said and done, and specific words used.
*
Your answer
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