JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Mammoth Spring School District Reporting Form
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name of person reporting
Your answer
Last Name of person reporting
*
Your answer
How can we contact you if needed? (Please provide phone number or email address)
*
Your answer
Name of victim
*
Your answer
Name of alleged harasser or bully
Your answer
Date and time of incident
MM
/
DD
/
YYYY
Location of the incident: (approximate location of the incident)
Classroom
Hallway
Restroom/Locker Room
Gym
Lunch/Commons
Option 6
Bus
Parking Lot
Before/After School sponsored activity
Away from school
Other:
Nature of Discrimination or Harassment
Age
Disability
Gender Identity
National Origin/Ethnic Background
Physical Attribute
Physical/Mental Ability
Race/Color
Religion
Sex
Sexual Orientation
Socioeconomic Background
Other:
Type of Harassment
Verbal
Physical assault
Electronic communication (cyber bullying)
Social/Relational (excluded from group...)
Other:
Description of the incident
*
Your answer
Name of witnesses (if any)
Your answer
Any other information:
Include reference to evidence you may have including text messages, posts, pictures...
Your answer
How often has this issue occurred?
This was the first time
5 times or less
6 times or more
Clear selection
Was this issue previously reported?
No, First time reported
Previously reported to bus driver
Previously reported to teacher
Previously reported to counselor
Previously reported to administrator
Previously reported to parent
Other:
I agree that all of the information is accurate and true to the best of my knowledg
*
YES
NO
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Mammoth Spring School District.
Report Abuse
Forms
