CRUESD Bullying Report Form- Confidential

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This form is a confidential way to report an incident of bullying. The form will only be seen by the school administration. Student's reporting the bullying do not have to provide their name, however, it will make it easier for school administration to investigate the report.

Name of Person Reporting Incident (Optional)

What is your role?

Student

Parent/Guardian

School Staff

Community Member

Clear selection

Reporting Person Contact Information (Optional):

Name(s) of identified target(s) (Optional):

Name(s) of alleged offender(s) (Optional):

Date and Time of Incident?

How often does the bullying occur (one time, weekly, daily):

Location of the incident(s):

Cafeteria

Classroom

Hallway

Restroom

Playground

Off Campus

Technology/Social Medie

Please select any of the following that occurred during the incident:

Cyberbullying

Damage of Property

Intimidation

Physical Violence

Public Humiliation

Social Bullying

Unwanted Physical Contact

Verbal Abuse

Other:

Please indicate if you believe the incident was related to discrimination based on any of the following:

Disability

Gender Identity/Expression

Race/Ethnicity

Religion

Sexual Orientation

Other:

Please describe the bullying incident(s) using as many details as possible:

The reporting person may remain anonymous. If you choose to remain anonymous, please explain (optional):

Submit

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This form was created inside of Castle Rock School. Report Abuse

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