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AMSHS Bullying Report Form
Please use this form to report any incident of bullying that you witness or has happened to you (or your child).
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Victim/Target(s)
Your answer
What is your name?
Your answer
What is your role?
Student
Parent
Faculty/Staff Member
Community Member
Other:
Clear selection
How can I contact you? Please type your email or phone number.
Your answer
Name of Aggressor/Bully (Person who engaged in the behavior. If you don't know their name, please do your best to describe them.)
Your answer
What was the bullying behavior?
Shoved/Pushed
Excluded
Staring/Leering
Cyber-bullying (text, website, email, other)
Racial, sexual, religious, or disability
Hit, Kicked, Punched
Taunting/Ridiculing
Intimidation/Extortion
Threatened
Demeaning Comments
Stole/Damaged Possessions
Told Lies or False Rumors
Inappropriate Touching
Other:
Clear selection
What happened? Describe the incident.
Your answer
Did anyone else see the incident happen? (List the people who saw the incident or have information about it)
Your answer
What day did this happen?
MM
/
DD
/
YYYY
Where did this happen?
On school property
At a school-sponsored activity or event off school property
On a school bus
On the way to/from school
Outside of school
Electronically (text, social media, etc)
Other:
Clear selection
Has this behavior happened before?
Yes
No
Clear selection
If yes, who did you report to about the problem
Parent
Babysitter
Brother/Sister
Other family member
Teacher
Other Staff Member
Other:
Is there any other information you would like to provide?
Your answer
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