Bullying Reporting Form

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Bullying Reporting Form

This bullying report is not monitored 24/7. If you need immediate assistance because you or your child are in danger of hurting yourself or someone else, please contact law enforcement. For help, call Arkansas Crisis Center 988.

Suicide Prevention Lifeline: 1-800-273-TALK

Directions: Reports of Bullying or Harassment that effect the learning environment or threaten student safety are serious allegations. Upon submission of this form, the Principal at the student’s school will be notified. Every reported act of bullying or harassment will be investigated and parents will be informed.

Anyone can make a report. All school employees are required to report alleged violations. This form can be completed anonymously by omitting the "Name of Person Reporting the Incident" field.

Contact the school for additional information or assistance at any time.

Victim's Name (Include Grade, Age, School) *

Name of 1st Alleged Offender (Include Grade, Age, School) *

He/She is a student? *

Yes

Required

Name of 2nd Alleged Offender (Include Grade, Age, School) *

He/She is a student? *

Yes

Required

What date did the initial event occur? *

What date did the 2nd event occur?

What date did the 3rd event occur?

Where did the event occur? *

On school property

At a school-sponsored activity off school property

At the bus stop

On a school bus

On the way to/from school

On the Computer

Required

Select the statement(s) that best describe what happened (choose all that apply)

Teasing/making fun of

Threat of harm

Stalking/Staring, following, intimidating, or trying to scare

Taking things or breaking others property

Cyber bullying/Posting hurtful or embarrassing things online or social media

Excluding/Being left out

Name Calling

Fighting/hitting/touching

Humiliation/embarrassment

Required

What did the alleged offender(s) say or do?

Did a physical injury result from this incident?

Yes, but it did not required medical attention

Yes, and it required medical attention

Required

Was the student victim absent from school as a result of the incident?

Option 1

Yes

Required

Is there any additional information you would like to provide?

Person reporting the incident. Include your name, telephone, email. (This is not required - You can submit anonymous)

Select from the choices below to best describe yourself:
*

Student

Parent/Guardian

Close relative/Other

Required

Submit

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