JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Anonymous Bullying Report Form
This report form is for any bullying that is witnessed. Your personal details such as your name are OPTIONAL, therefore you can submit a report while remaining anonymous.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Your name (OPTIONAL)
Your answer
I am a
*
Student
School employee
Parent/Guardian
Person being bullied
Concerned citizen
Friend
Have you reported the incident to anyone in authority?
*
Choose
Yes
No
If you have reported the incident, who did you report it to?
Your answer
Name of alleged bully
*
Your answer
Name of the person allegedly being bullied
*
Your answer
Date of incident
*
MM
/
DD
/
YYYY
Time of incident
Time
:
AM
PM
Location of incident
*
At school
On a bus
Other:
What happened?
*
Physical: Hitting, kicking, or other physical aggression
Verbal: Teasing, name-calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad
Exclusion: starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without frineds
Cyber-bulling: Using a computer, cell phone, or other electronic device to engage in any previously mentioned bullying
Other:
Required
Details of the incident
Your answer
Did you witness what happened?
*
Choose
Yes
No
Please list other persons that witnessed the incident.
Your answer
Additional comments
Your answer
Your contact information (OPTIONAL)
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of International Programs School.
Report Abuse
Forms
