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AMSHS Bullying Report Form
Please use this form to report any incident of bullying that you witness or has happened to you (or your child).
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詳細
Victim/Target(s)
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What is your name?
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What is your role?
Student
Parent
Faculty/Staff Member
Community Member
その他:
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How can I contact you? Please type your email or phone number.
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Name of Aggressor/Bully (Person who engaged in the behavior. If you don't know their name, please do your best to describe them.)
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What was the bullying behavior?
Shoved/Pushed
Excluded
Staring/Leering
Cyber-bullying (text, website, email, other)
Racial, sexual, religious, or disability
Hit, Kicked, Punched
Taunting/Ridiculing
Intimidation/Extortion
Threatened
Demeaning Comments
Stole/Damaged Possessions
Told Lies or False Rumors
Inappropriate Touching
その他:
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What happened? Describe the incident.
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Did anyone else see the incident happen? (List the people who saw the incident or have information about it)
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What day did this happen?
YYYY
/
MM
/
DD
Where did this happen?
On school property
At a school-sponsored activity or event off school property
On a school bus
On the way to/from school
Outside of school
Electronically (text, social media, etc)
その他:
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Has this behavior happened before?
Yes
No
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If yes, who did you report to about the problem
Parent
Babysitter
Brother/Sister
Other family member
Teacher
Other Staff Member
その他:
Is there any other information you would like to provide?
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