Anonymous reporting of bullying in your school
This is optional - you do not have to share your name
I have reported this event to my school
I am a
Person being bullied
Type of bullying, harassment, or discrimination: (Check all that apply)
Cyber bullying: Takes place in cyberspace. This type of bullying involves various forms of victim harassment, including repeatedly posting pictures of the victim on websites against his/her wishes and sending pictures through cell phone texting.
Emotional bullying: To repeatedly exclude the victim from social situations and cause mental pain while leaving the victim feeling alone.
Physical bullying: Injury to the person or his/her belongings is characteristic of this method. The bully may have repeatedly punched, kicked, shoved, or spit on the victim.
Verbal bullying: The person will repeatedly say put-downs and rude things directly to the victim, usually in front of his/her friends or peers.
Harassment/Discrimination: Is unwanted, unwelcome, and uninvited behavior that belittles, offends and threatens causing one to feel physically or emotionally unsafe. It is based on race, national origin, color, sex, age, disability and/or religion.
I recently saw some information and/or a social media post about a student contemplating suicide. Attach information below in the Link to supporting documentation.
Name of person bullied:
This information is required in order to investigate the report.
Burke Middle College
East Burke High
East Burke Middle
Forest Hill Elementary
George Hildebrand Elementary
Glen Alpine Elementary
Mountain View Elementary
North Liberty School
Oak Hill Elementary
Ray Childers Elementary
Table Rock Middle
Walter Johnson Middle
WA Young Elementary
Name of person DOING the bullying:
This could be a student or adult.
Were you there when the incident occurred?
List other students or adults who witnessed the incident:
If no witnesses, enter the word "NONE"
Who has been told about the bullying? (Check all that apply):
If Other, please specify in the area provided.
Other adult in school
Sibling (brother or sister)
Where did the bullying occur? (Check all that apply):
If other, please specify in the area provided.
In class with teacher
In class without teacher
What date did the bullying occur?
Please describe what happened.
Include where and when the incident occurred.
Link to supporting documentation
For Office Use Only:
Administrator Action Taken:
Never submit passwords through Google Forms.
This form was created inside of Burke County Public Schools.