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Report Bullying or Unsafe Behavior
Use this from to report bullying, sexting, substance use/abuse, or any unsafe or unhealthy behavior.
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Reporter's Name
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Your answer
Bully's Name
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Your answer
Student Bullied
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Your answer
Date(s) of Incident:
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Time of Incident:
Your answer
Location bullying occurred:
Your answer
Witnesses:
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Adults made aware of the event:
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Check All That Apply
Disregard for another's personal space (Physical or Non/Physical)
Practical jokes, which may result in embarrassment or awkwardness
Name calling (teasing, making fun, etc.)
Insults (put downs)
Insulting "slang" terms regarding (gender, race, ethnicity, etc.)
Gossip/Rumors
Inappropriate pictures, drawings, and/or materials
Stealing of money or other possessions
Intentionally excluding others
Other
Description of the incident:
Your answer
If this report involves social media, keep/save any evidence for the counselor or principal.
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