Bullying/Harassment Reporting Form

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Please complete this form if you are a victim of bullying or harassment, or if someone you care about is. The responses will be delivered anonymously to the Superintendent/Principal of Bethel Grade School.

What best describes you? *

I am a victim

I am a witness

I am a parent

I am a concerned community member

Is the behavior in question taking place at school? *

Yes

What type of contact is being made between the victim and the bully or harasser? Check all that apply. *

Name-calling

Physical Aggressions

Verbal Threats

Purposeful Exclusion

Online Threats

Online Name-Calling

Text Message Harassment

Rumors being Spread

Other:

Required

Please describe in detail (names, dates, times and places) what is taking place. *

If you would like to be contacted about this, please provide your contact information.

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