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Stewartville Middle School Bullying Report Form
This is a safe form to use If you feel you have been the target of bullying, harassment or other unkind behaviors or have witnessed or know of others doing such behaviors.
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* Indicates required question
Your Name (Last, First)
*
Your answer
What grade are in you in?
*
6th
7th
8th
Parent or family member
Teacher
Parent of a friend of the target
Younger or older student (not in middle school)
Sibling
Required
Name of student being targeted (Last, First)
*
Your answer
Grade level of student being targeted
*
6th
7th
8th
Older or younger student/not in middle school
Other:
Name of student(s) who is doing the negative behavior(s)?
*
Your answer
Please select the targeting behavior(s) from the following list
*
Excessive teasing or mocking
Physical (hitting/pushing/jostling/tripping)
Name calling
Abusive language or swearing
Excluding (not allowing to participate in an activity or join a group)
Online/social media harassment or bullying
Other:
Required
This negative behavior has occured ...
*
in the hallways
in the classroom
in the cafeteria
in the hall locker area
in the locker room
on the bus or at the bus stop
other?
Required
Please list witnesses you know (have) observed the negative behavior
Your answer
Please check the adults who have knowledge of the situation
*
Teacher
Parent
Counselor
Principal
Parent of a friend
No other adults currently know about this
Other:
Required
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