Brown Bullying Report
Please complete this form with as much detail as possible.
Who does this report involve *
Required
During this incident I was a: *
Describe the Incident in detail. *
What grade are you in? (optional)
Clear selection
Who did this? If you do not know, do your best to describe the student. *
Where did this incident take place? *
Required
Were there witnesses to this incident? *
What are the names of the witnesses? (optional)
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
Major incident
Please describe the frequency with which this type of incident occurs. *
One time incident
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) *
Did this or other incidents make you feel like harming yourself or others? *
Would you like to speak with a counselor? If yes, please add your name below. *
Your Name
What else would you like for us to know about this incident?
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