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Bullying, Harassment, or Intimidation Reporting Form 2021-2022
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* Indicates required question
Email
*
Your email
Name of Person Reporting
*
Your answer
Name (s) of student(s) being harmed
*
Your answer
Name(s) of people who saw the situation
Your answer
Name(s) of student(s) who harmed another student(s)
*
Your answer
Date the incident happened
MM
/
DD
/
YYYY
Time the incident happened
Time
:
AM
PM
How often have these incidents been happening?
*
1 time
2-3 times
4-5 times
More than 5 times
Where did the incident take place? (select all that apply)
*
Classroom
Hallway
Bathroom
Cafinasium
School Bus
Playground/Outside
Other:
Required
How did this happen?
*
In person
Email
Text
Social Media
Required
Did this happen during school hours or at a school sponsored event?
*
Yes
No
Select the statement(s) that best describe what happened (choose all that apply).
*
Physical aggression towards a student
Spreading harmful rumors, gossip, or lies
Excluding or rejecting a student
Making rude gestures/actions
Teasing, name-calling, rude comments, or threats
Stolen of destruction of property
Required
Details of the incident.
Your answer
Is there evidence of the incident?
*
Yes
No
Maybe
Send me a copy of my responses.
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