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Peer Conflict or Bullying Reporting Form
Please fill out this form so the school counselors and principals can assist you with any issues you are experiencing with peer conflict or bullying during the course of the school day or on the school bus. You can submit this report anonymously or include your name.
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* Indicates required question
Your name (First and Last Name)
*
Your answer
Your Grade
*
5
6
7
8
When did the bullying occur?
*
MM
/
DD
/
YYYY
Name of student (First and Last Name) you consider to be bullying you
*
Your answer
How often does this occur
*
Daily
Weekly
This is the first time
Where did the bullying occur?
*
School bus
Classroom
Hallway
Restroom
If this occur on a school bus, in a classroom, restroom or hallway, please be specific. (Provide bus #, classroom, restroom location or hallway where the incident is occurring)
*
Your answer
Describe what happened?
*
Your answer
Have your reported this previously?
*
Yes
No
Please provide the names (First & Last) of any witnesses to the reported incident.
*
Your answer
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This form was created inside of HOPEWELL AREA SCHOOL DISTRICT.
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