Bullying Reporting Form

Please complete this form to the best of your knowledge so we can assist you.
This information will be kept confidential with your campus administrator and/or superintendent.

 

Please Fill Out The Bullying Report Form Below

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Reaquired field:Date of Incident: 

 

Reaquired field:Date of Report: 

 

Who was the person(s) engaged in bullying?

 

Grade of person(s) who engaged in bullying?

 

Who was being bullied?

 

Grade of person who was being bullied?

 

What type of bullying?

 Physical

 

 Emotional/Social

 

 Damage to Property

 

 Online

Where did the incident take place?

 After School Program

 

 Bus

 

 Bus Stop

 

 Cell Phone

 

 Classroom

 

 Hallway

 

 Gym

 

 Internet

 

 Locker Room

 

 Lunch Room

 

 Parking Lot

 

 Playground

 

 Restroom

 

 School Sponsored Event

 

Other:

Other location details: (Please explain the specific location details such as which hallway, where on the Internet, what restroom, etc)

Describe what happened with as many details as possible.

Person reporting the incident:(OPTIONAL). Please use your full name.

 

May we contact you for more information on this incident?

 Yes

 

 No

Thank you for reporting this incident. We appreciate your concern. When you click "Submit Form" this will be sent to system administration.

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 Required Fields