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Student Bullying Form
Bullying is a series of repeated, purposeful and hurtful acts.
Paper forms are also available. Please see your teacher, or the office to get a copy.
Forms can be turned in to any staff member.
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* Indicates required question
Name of person making report (optional)
Your answer
Person making the report is: (optional)
Student
Parent
Grandparent
Guardian
Friend
School Staff
Other
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Contact information for reporting person: (optional)
Your answer
Name of person being targeted:
*
Your answer
Please specify grade of targeted student.
Your answer
Names of the perpetrators of the bullying behavior.
Your answer
Date(s) of the incident(s)- approximate if necessary:
Your answer
Location of incident(s)
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Were there any witnesses? If so, who?
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Please provide a description of the incident(s)- please be as specific as possible.
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Thank you for your report. The Administration will investigate and handle this with immediacy. If there is anything more you would like us to know, add it here:
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