Bullying Report
Reported By (Optional Name)
I am a *
Grade Level *
Name of Alleged Bully (Description if student name is unknown) *
Behavior (select ALL that apply) *
Required
Incident Description *
Location *
Who were/are all the people involved with the bullying or harassment?
 *
What time did/does the bullying or harassment occur? If exact time is unknown, please describe the time of day (example: recess, lunch, period of the day, before/after school)
 *
Is this the first time? If not, how often does the bullying or harassment occur?
 *
When did the most recent incident of bullying or harassment occur?
 *
MM
/
DD
/
YYYY
Why do you believe this bullying or harassment is happening?
 *
Do you have any additional evidence that supports the bullying or harassment? (text messages, emails, social media posts, written notes, or other evidence)
 *
Has anyone else (students, peers, or adults) have witnessed the bullying or harassment or have knowledge of the bullying or harassment? If yes, who?
 *

Do you believe other people at school, are also being bullied or harassed by the same person/people? If yes, who?

 *

Has the person/people that are bullying or harassing you made any threats (directly or indirectly) to attack, harm or injure someone at school? (examples: comments, statements, writings, or posts about carrying out a violent attack against others. This information could have been made verbally, in writing, or via social media. The threat could have been heard first-hand or from someone else in the form of a rumor). Include as many details as possible

 *
Have you had conflict with this student in the past? *
Additional information that might be helpful in the investigation (Optional)
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Aventura City of Excellence School. Report Abuse
Google Forms