3. Your telephone number and/or email address (optional)
Your answer
4. Are you a: *
5. Name of student (s) being bullied: *
Your answer
Student's Grade Level and Teacher: *
Your answer
6. Name of alleged offender: *
Your answer
Alleged Offender's Grade Level and Teacher:
(if known)
Your answer
7. Is the alleged offender older or younger than the person being bullied? *
8. Date of the incident *
MM
/
DD
/
YYYY
9. Name of any other person that could have seen the incident and could provide more information.
Your answer
10. Where did the incident occur (check all that apply) *
Required
11. Check the statement that BEST describes what happened: *
Required
12. Does this meet the definition of bullying? Definition: Intentionally aggressive behavior, repeated over time and involves an imbalance of power. If so, provide more information in Question #15. *
13. To your knowledge, has this been reported before? *
14. If you answered "YES" to question #13, did someone respond within 24 hours? If not, did you follow up with a phone call to the school administrator for assistance and what was the outcome?
Your answer
15. Is there any additional information that you would like to provide? If NO, respond with "NA". *
Your answer
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