TMS Bullying Report Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This is a form to report alleged bullying that occurred during the current school year on school property, at a school-sponsored activity or event off school property, on a school bus, on the way to and/or from school, or on the internet-sent on or off school property. A student is being bullied when they are exposed to negative actions on the part of one or more students and there is a real, or perceived, imbalance of power. If you are unsure if the incident(s) are bullying, submit the form to allow the school to investigate. Name, email, and cell number are all optional, but we would appreciate the opportunity to talk to you about the incident.
TMS Administration

Person Reporting *

Student - Experienced bullying

Student - Witness

Parent of student who experienced bullying

Parent of student witness

Community Member

Other:

Optional: Name of reporter

Optional: Email address of reporter

Optional: Phone number of reporter

Name of student who experienced bullying (If unknown, please describe the student). *

Name of student(s) who witnessed the bullying (If unknown, please describe the student(s)). *

Name of student(s) who participated in the bullying (If unknown, please describe the student(s)). *

Incident date the bullying occurred. *

YYYY

Describe what happened or use the next section to select a statement

Select a statement that best describes the incident.

Cyber bullying (e.g. social media including Facebook, Twitter, Vine, Instagram, etc.)

Electronic communication (e.g. email, text, sexting, etc.)

Excluding or rejecting the student

Spreading harmful rumors or gossip

Making rude and/or threatening gestures

Physical aggression such as hitting, tripping, kicking, etc

Getting another person to hit or harm the student

Demeaning and making the student the center of jokes

Teasing, name-calling, making critical remarks, or threatening, in person or by other means

Teasing, name-calling, making critical remarks, or threatening related to the student's disability

Teasing, name-calling, making critical remarks, or threatening related to the student's perceived sexual orientation

Teasing, name-calling, making critical remarks, or threatening related to the student's perceived race.

Where did the incident happen? (Select all that apply.) *

On school property

At a school-sponsored activity or event off school property

On a school bus or school van

On the way to/from school

Via Internet - sent on or off school property

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Templeton Unified School District.

Does this form look suspicious? Report

Forms