BULLYING REPORT FORM

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This form should be completed to report suspected bullying 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 if you provide your contact information.

Please note that by filling out this form, you understand that a member of the Bullying Intervention Team will contact the student suspected of getting bullied.

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 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

Your First and Last Name (person reporting)

I am a *

Student

District/School Employee

Parent

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