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BULLYING BEHAVIOR REPORT FORM
This form should be completed to report suspected bullying by others to Positive Youth Development.
(This may include alleged bullying behavior, harassment, discrimination, injury or cyber-bullying related incidents.)
This form is only monitored during school hours M-F. Your response will be recorded and our office will contact you within 24 business hours if you provide your contact information.
Please note that by filling out this form, you understand that a member of the Positive Youth Development's Bullying Intervention Team will contact the student suspected of getting bullied.
* Required
HAVE QUESTIONS?
If you have any questions or need assistance with completing this bullying report form, please contact Positive Youth Development ​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!
Please note: The Bullying Intervention Team:
- will not share WHO made the report to the school
- will share with the school that a report was made to our office
- will contact the student who is getting bullied to begin the process in response to this concern
I wish to keep my name confidential from the school.
*
No
Yes
Other:
REPORTING PERSON
First Name
Your answer
Last Name
Your answer
I am (check one)
Student
Parent
Friend
Staff
Other:
Clear selection
I am (check one)
Person who is getting bullied
Person who witnessed bullying
Person who is concerned about bullying
Clear selection
CONTACT INFORMATION
Telephone number
Your answer
Email address
Your answer
BULLYING BEHAVIORS
Date of incident (if known)
MM
/
DD
/
YYYY
School where student currently attends
*
Your answer
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
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
Did you report the bullying to someone at the school?
*
YES
NO
If yes, who did you report it to?
*
Teacher
Counselor
Vice Principal
Prinicpal
Support staff
I did not report this to anyone
Other:
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)
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