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Bullying Report Form
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* Indicates required question
Your Name (Optional)
Your answer
School associated with incident:
*
Madelia High School
Madelia Elementary
Required
I am a:
*
Student
School Employee
Parent/Guardian
Person being bullied
Concerned Citizen
Friend
Other:
Required
Have you reported this incident to anyone in authority?
*
Yes
No
The alleged bully is a:
*
Student
School Employee
Name(s) of alleged bully(ies):
*
Your answer
Name of the person allegedly being bullied:
*
Your answer
Location of the alleged incident:
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At School
On a bus
Athletic Event
Other:
What happened?
*
Physical: Hitting, kicking, or other physical aggression
Verbal: Teasing, name-calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad
Exclusion: starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends
Cyber-bulling: Using a computer, cell phone, or other electronic device to engage in any previously mentioned bullying
Other:
Required
Description of what happened:
*
Your answer
Please list other persons that witnessed what happened:
Your answer
Additional Comments:
Your answer
Your Contact Info (Optional) Email/Phone Number
Your answer
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