MHS Bully Report Form

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Instructions:
Please complete the form to report an incident of bullying. Respond only to the questions that you feel comfortable answering and are able to accurately answer. You may choose to include your name (which
will be confidential) at the bottom of the form or you may submit it anonymously.

Disclaimer: If you are not comfortable providing your name on this form, please seek a trusted adult to voice your concerns.

Email (optional)

Name of Affected Student
*

Date of incident
*

YYYY

Approximate time of incident
*

Time

Location of Incident
*

Who was bullying? (If you do not know the person's name, please describe him/her.)

Who was the target of the bullying? (If you do not know the person's name, please describe him/her.)

I was the target of the bully.

Other:

Clear selection

Did anyone witness the bullying? If yes, please give name or description of him/her.

Have you reported the incident to anyone else? If yes, who?

Have you previously filed a bullying report (this information is used to determine if retaliation is occurring)?

Yes

Clear selection

Give as many details as you can about the incident. What happened? What was the bullying behavior?
*

Your grade and age

Your name (Optional)

Submit

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