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BULLYING BEHAVIOR REPORT FORM
This form should be completed to report potential bullying by others to Youth Services Department.
(This may include alleged bullying, behavior, harassment, discrimination, injury or cyber-related incidents.)
* Required
HAVE QUESTIONS
If you have any questions or need assistance with completing this bullying report form, please contact Youth Services Department by calling 909-880-6812
BULLYING DEFINITION
Bullying is unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time. Both (students) who are bullied and who bully others may have serious, lasting problems.
CONFIDENTIAL!
We will NOT share the person's name who made this report with the school, but we will work with the school to stop the bullying.
REPORTING PERSON
First Name (optional)
Your answer
Last Name (optional)
Your answer
I am (check one)
*
Student
Parent
I am (check one)
*
Person who is getting bullied
Person who witnessed bullying
Person who is concerned about bullying
CONTACT INFORMATION (optional)
Telephone number (optional)
Your answer
Email address (optional)
Your answer
BULLYING BEHAVIORS
Date of incident (if known)
MM
/
DD
/
YYYY
School
*
Your answer
Describe what happened
*
Your answer
Please check the box that best describes what the bullying behaviors look like. Please choose all that apply.
*
Physical: Hitting, kicking, shoving, spitting, etc.
Getting another person to hit or harm the student
Teasing, name calling, put downs, criticizing, jokes
Property issues (hiding, damaging, taking)
Threatening in person, by phone, by e-mail, etc.
Spreading harmful rumors or gossip
Demanding money/homework/etc.
Cyberbullying: social media, etc.
Other:
Required
PERSON(S) THE BULLYING INVOLVES (IF KNOWN):
First Name of person getting bullied
*
Your answer
Last Name of person getting bullied
Your answer
First Name of person doing the bullying (if known)
Your answer
Last Name of person doing the bullying (if known)
Your answer
Did you report the bullying to someone at the school?
YES
NO
Clear selection
If yes, who did you report it to?
Your answer
I agree that all of the information on this form is accurate to the best of my knowledge.
*
YES
NO
Thank you for completing this form. Each complaint of bullying will be promptly investigated to determine how we can help to change the situation.
(Education Code 234.1)
Would you like us to contact you?
*
YES
NO
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