Bullying Report Form
Argosy Collegiate Charter School
1.   Name of Person Filing this Report: (Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the  basis of an anonymous report.) Please write "anonymous reporter" if you do not wish to identify yourself. *
2. Check whether you are the:   *
Required
3. Check whether you are a(n): *
Required
4. If you selected "other" in question 3, please specify:
5. Optional: If choosing to fill out this report with your name, please list your contact information/telephone number:
 6. If scholar, select your grade:  
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7. Name of suspected Target (person you believe is being bullied) *
8. Name of suspected Aggressor:  (person you believe is doing the bullying) *
9. Has there been more than one incident between the target and the aggressor that you are aware of?   *
10. Is there an imbalance of power between the target and the aggressor that you can identify?  Please explain. *
11. Does the aggressor’s behavior (including cyber-behavior) do at any of the following?: (a)  causes physical or emotional harm to the target or damage to the target's property; (b)  places the target in reasonable fear of harm to himself or herself or damage to his or her property;(c)  creates a hostile environment at school for the target; (d)  infringes on the rights of the target at school; or (e)  materially and substantially disrupts the education process or the orderly operation of a school *
12. Describe the incident(s) that have occurred that have caused you to be concerned about bullying: *
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