St Agnes School Bullying Report Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

You may remain anonymous to report bullying incidents at the school or you may set up an appointment to speak with staff. This form will remain anonymous unless you submit additional information below in question 10. Electronic version is available on our website stagnesschoolvermillion.org/home

I am a: *

Student

School Employee

Person Being Bullied

Friend

Parent

Other:

Person being bullied *

Location *

Date: *

YYYY

Name of Alleged Bully *

Type of Event *

Physical-Hitting/Kicking/Other Physical Aggression

Verbal-Teasing, Name Calling, Put Downs, or Other Behavior that would hurt others' feelings or make them feel bad

Emotional/Exclusion-Starting Rumors, Telling others not to be friends with someone or other actions that would cause someone to be without friends

Cyber Bullying-using an electronic device to engage in any previously mentioned bullying

Required

Description of Events: *

List other students/staff that witnessed the event: *

You can submit your form several ways: *

Mail to the school; St Agnes School 909 E Lewis Street Vermillion SD 57069

Drop in the drop box outside the Principal's office

Fill out the form on the website, Stagnesschoolvermillion.org

Set up a time to meet with Mrs. Pohlson to return your form

Required

If you would like to set up a meeting with Mrs. Pohlson or other staff members please leave your contact information below and the best time to contact you. This question is not required, you only need to fill out this question if you would like to meet about this bully incident. If you would like to remain anonymous, please skip this question.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of St Agnes Catholic Elementary School. Report Abuse

Forms