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.
Describe what happened/what is happening *
Your answer
When did/does this bullying occur? *
Your answer
Where did/does this happen? *
Your answer
Who was doing the bullying? *
Your answer
Who was being bullied *
Your answer
Please list any witnesses to the bullying.
Your answer
Have you told anyone about the bullying?
Your answer
Your Name (optional but helpful if necessary for follow-up)
Your answer
Your Grade or Grade Level of the Student being bullied *
Your email address (optional)
Your answer
Are you willing to visit with a school counselor or administrator regarding this incident?
Other information you would like to include. You may also include a telephone number if you would like someone to contact you about this.
Your answer
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This form was created inside of WESTVILLE SCHOOL.