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Lutheran Central School Bully Reporting Form
Please provide as much detail as possible to help us deal with the problem effectively.
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* Indicates required question
Name of person being bullied
*
Your answer
Date
*
MM
/
DD
/
YYYY
Name of bully
*
Your answer
Your Name (optional)
Your answer
I am a
*
Student
Staff Member
Parent/Guardian
Person being bullied
Community Member
Friend
Type of Bullying (Select all that apply)
*
Physical- Hitting/kicking other physical aggression
Verbal- Teasing, name calling, put-downs, or other behavior that would others' feelings or make them feel bad.
Emotional/Exclusion-Starting rumors, telling others not to be friends with someone or other actions that would cause someone to be without friends.
Cyber-bullying- Using an electronic medium (including but not limited to: texts, e-mails, phone messages, facebook, etc.) to previously mentioned "bullying."
Required
Description of events (Please be specific-use exact wording, names, dates, location and time, etc.)
*
Your answer
Did you witness the bullying?
*
Yes
No
Please list other students/staff who may have witnessed the bullying incident described above
Your answer
The administrators will investigate the report and take appropriate actions to deal with the situation. Since much of waht we do needs to remain confidential, you may not know of the steps we take to stop bullying. If the bullying does not stop, we need to take additional steps. Please let us know if the bullying continues.
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