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Juniper Elementary School Bully Prevention Reporting Form
Please utilize this form to report purposefully hurtful behaviors that persist after an aggressor has been asked to stop. All reports will be investigated and followed up on as soon as possible.
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* Indicates required question
Name of Reporting Party
*
First and Last Name
Your answer
Are you a student, parent, staff member, etc?
*
Student
Parent
Staff Member
Other:
How did you obtain this information?
*
It happened to me.
I witnessed it.
The target (victim) told me about it.
A bystander (witness) told me about it.
Other:
Required
Name of the Target (Victim)
*
Please list the first and last name of the person who has been bullied.
Your answer
Teacher of the Target (Victim)
Please list the teacher of the student who has been bullied, if known.
Your answer
Name of the Aggressor (Bully)
*
Please list the first (and last if known) name of the aggressor (bully).
Your answer
Teacher of the Aggressor (Bully)
Please list the name of the teacher of the aggressor, if known.
Your answer
Bystanders (Witnesses)
Please list the names of any bystanders who witnessed the bullying behavior.
Your answer
Approximate Time of Incident
*
Check any that apply.
Before School
During the school day, before lunch
During lunch or lunch recess
During the school day, after lunch
After school
Unknown
Required
Location of Incident
*
Please describe exactly where the incident took place.
Your answer
Type of Bullying
*
Check all that apply.
Verbal (name-calling, teasing, insults, sexual or racial comments)
Intimidation (threats, taking or damaging possessions, purposeful exclusion)
Cyber (online bullying via texting or social media)
Physical (physical aggression, physical assault)
Other:
Required
Has the target (victim) asked the aggressor (bully) to stop the behavior?
*
Yes
No
Unknown
Has the target (victim) reported the incident to a staff member? If so, to whom?
*
Yes, it was reported to a teacher. Please list the teacher name under "Other" if known.
Yes, it was reported to a proctor. Please list the proctor name under "Other" if known.
Yes, it was reported to an administrator.
Yes, it was reported to a bus driver.
No, it was not reported to a staff member.
Other:
Required
Description of Incident
*
Please describe what happened. Please include details about how the aggressor has been asked to stop or informed that his or her behavior was hurtful or unwanted.
Your answer
PARENTS: IF YOU WOULD LIKE TO RECEIVE A TEXT MESSAGE TO CONFIRM THAT THIS FORM HAS BEEN RECEIVED, PLEASE LEAVE YOUR NAME AND CELL PHONE NUMBER BELOW.
STUDENT REPORTERS WILL BE CONTACTED IN PERSON AT SCHOOL.
Your answer
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