ASD4- Bullying Incident Report Form
If you are the victim of bullying or witness bullying at school, on the bus, or online, please use this form to report it. This form will be submitted to administration. Reports are confidential. Tip-off reports are checked Monday through Friday during normal business hours.

Thank you for helping us to maintain a positive and safe school environment for all of our students. (All names provided are kept confidential.)

Name (optional)
Your answer
Today's date (optional)
MM
/
DD
/
YYYY
Email (optional)
Your answer
Phone number (optional)
Your answer
Would you like to be contacted? *
Please choose a school: *
Please choose a grade: *
Date incident occurred *
MM
/
DD
/
YYYY
What was the location of the incident (ex. lunchroom, bus, etc.) *
Your answer
Describe the incident(s) and how long the incident(s) have taken place. Be specific as possible. *
Your answer
Were there any witnesses to the incident(s)? If so, who? *
Your answer
Have you notified school staff about the incident(s)? Who was notified and when? *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Addison School District #4. Report Abuse - Terms of Service