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Powers Lake School Bullying Form
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* Indicates required question
Email
*
Your email
Describe what happened/what is happening:
*
Your answer
When did it happen?
*
Before school
During school
After school
Unsure
Date & time
Date
*
MM
/
DD
/
YYYY
Time
Time
:
AM
PM
Where did it happen?
*
In the school building (list specific room):
On the school playground
In the school parking lot
On the school bus
Online
At a school event
Other
Unsure
Who was committing the bullying (if you don’t know the bully’s name(s) describe him/her?
*
Your answer
Who was the victim of the bullying (if you don’t know his/her name, describe him/her)?
*
Your answer
Did anyone else witness the bullying (if yes, please list)?
Your answer
Were you or others physically hurt (please explain)?
Your answer
Was there damage to anyone’s
personal property?
Yes
No
Unsure
Clear selection
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)?
*
Yes
No
Unsure
Have you told anyone about the bullying?
Parent
Babysitter
Brother/sister
Other family member:
Teacher
Other school staff:
Clear selection
Have you previously filed a bullying report (this information is used to determine if retaliation is occurring)?
*
Yes
No
Your name: (Optional)
Your answer
Your grade and age: (Optional)
Your answer
How can we contact you?
Your answer
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