Brown Bullying Report
Please complete this form with as much detail as possible.
* Required
Who does this report involve
*
Student at Brown Elementary School
Other:
Required
During this incident I was a:
*
victim
Witness
Describe the Incident in detail.
*
Your answer
What grade are you in? (optional)
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth grade
Not a current student
Parent
Staff Member
Other:
Clear selection
Who did this? If you do not know, do your best to describe the student.
*
Your answer
Where did this incident take place?
*
Classroom
Hallway
Bus
Cafeteria
Off School Property
Other:
Required
Were there witnesses to this incident?
*
Yes
No
Maybe
What are the names of the witnesses? (optional)
Your answer
Please rate the severity of this incident from your perspective, 1 being minor incident but unacceptable to 5 being major incident, could result in retaliation or violence.
*
Minor, but unacceptable
1
2
3
4
5
Major incident
Please describe the frequency with which this type of incident occurs.
*
One time incident
1
2
3
4
5
Every day
How do you feel about this incident or person? (Examples: they are annoying, I hate them, I want to hurt them, they don’t make me mad I just want it to stop…etc)
*
Your answer
Did this or other incidents make you feel like harming yourself or others?
*
Yes
No
Maybe
Would you like to speak with a counselor? If yes, please add your name below.
*
Yes
No
Your Name
Your answer
What else would you like for us to know about this incident?
Your answer
Submit
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