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Anonymous Bully Report Form
This form is anonymous. Email addresses and names are not being collected unless you decide to leave your name. When completing the form, please provide as many details as possible.
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* Indicates required question
Date of Incident
*
MM
/
DD
/
YYYY
Name(s) of person(s) being bullied
*
Your answer
Who was doing the bullying? (If you do not know a name, please describe the individual.)
*
Your answer
Did you witness the incident?
*
Yes
No
Who else witnessed the event? (Please include any staff member or other students who may have seen the event) (Please put N/A if noone else witnessed the event.)
*
Your answer
Time of incident (before school, lunch, after school, during class, in-between classes) If during class or between classes, please indicate which class or between which hours.
*
Your answer
Location of incident (gym, locker room, hallway, cafeteria, classroom, bus, playground, front lawn) Please be as specific as possible. For example, which part of the gym?, which classroom?, by which locker?, on which bus?
*
Your answer
Please describe the incident.
*
Your answer
Your Name/Person completing the form (NOT REQUIRED)
Your answer
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