Bullying Report Form - Motsenbocker

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This form can be used by parents & students to report concerns of bullying. Our administration and mental health team members will collaborate to investigate all reported incidents.

The definition of bullying is unwanted, intentional, aggressive, and intimidating behavior repeated over time.

For more information on bullying, please visit American Academy Student Support Services.

I am a... *

Parent

Student

Your name (first & last, or leave blank to report anonymously).

Email (optional)

Phone number (optional)

Name of student(s) DEMONSTRATING the bullying behavior. *

Name of student(s) TARGETED BY bullying behavior. *

Name(s) of potential witnesses

Location(s) of incident(s): *

Playground

Cafeteria

Carpool

Classroom

Bathroom

Hallway

Text/phone/internet/social media

After-school program/extracurricular activity

Other:

Required

Type of bullying (select all that apply) *

Verbal (saying or writing hurtful things)

Physical (hurting a person's body or possessions)

Social/relational (hurting someone's reputation or relationships)

Cyberbullying (bullying that takes place using electronic devices and mediums)

Required

Describe the bullying incidents) *

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