Bullying report form

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"Bullying" means any aggressive and unwanted behavior that is intended to harm, intimidate, or humiliate the victim; involves a real or perceived power imbalance between the aggressor or aggressors and victim; and is repeated over time or causes severe emotional trauma. "Bullying" includes cyber bullying. "Bullying" does not include ordinary teasing, horseplay, argument, or peer conflict.
Code of Virginia § 22.1-276.01.

All reporting will go to the confidential file of the school counselors. After reviewing reports, appropriate school personnel will investigate and intervene appropriately based on determination of information gathered.

Name of student who is repeatedly being bullied. *

Name of student who is repeatedly doing the bullying. *

When did the repeated bullying incidents occur? Specific dates or how long repeated bullying has been going on *

Where did the repeated bullying incidences happen. *

Classroom

Hallways

Cafeteria/ Outdoor eating area

Recess

Bus

Encore (PE, Art, Music, STEAM)

Other:

Required

Type of bullying that occurred (check all that apply)

Physical (e.g purposefully hitting, pushing, and kicking)

Verbal (e.g teasing, name-calling)

Relational (e.g isolation, refusing friendship)

Cyber (e.g texting, social media)

Description of repeated bullying incidents *

Witnesses (if any known)

Has the bullying been reported to an adult?

Yes

Clear selection

What adult did you report the bullying to?

Submit

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