Bullying Report Form
This form is confidential. Your contact information is optional. If this is an emergency situation, please call the appropriate school office to report.
What is today's date? *
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YYYY
Describe what happened/what is happening *
When did/does this bullying occur? *
Where did/does this happen? *
Who was doing the bullying? *
Who was being bullied *
Please list any witnesses to the bullying.
Have you told anyone about the bullying?
Your Name (optional but helpful if necessary for follow-up)
Your Grade or Grade Level of the Student being bullied *
Your email address (optional)
Are you willing to visit with a school counselor or administrator regarding this incident?
Clear selection
Other information you would like to include. You may also include a telephone number if you would like someone to contact you about this.
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