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Bullying Report
If you see something, say something! Help make your school safer for everyone. Please answer thoroughly and honestly.
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* Indicates required question
Describe what happened/what is happening:
*
Your answer
When did it happen?
Before School
During School
After School
Not Sure/Unable to say
Clear selection
Where did it happen?
In the school
On the school playground
In the school parking lot
On the Bus
Online
At a school event
Who was committing the bullying? (if you don't know the name, please describe the best you can)
Your answer
Who was the victim of bullying? (If you don't know the name, please describe the best you can
Your answer
Did anyone else witness the bullying?
Yes
No
Maybe
Clear selection
Was anyone (including you!) physically hurt?
Yes
No
Maybe
Clear selection
Was the damage to anyone's personal property?
Yes
No
Maybe
Clear selection
Have you or the victim missed school or changed your daily routine as a result of the incident(s)?
Yes
No
Maybe
Clear selection
If you answered "yes" to the previous question, please describe how:
Your answer
Have you told anyone about the bullying?
Parent
Teacher
Babysitter
Brother/sister
Other Family member
other school staff
Other:
Clear selection
Have you previously filed a bullying report? (We ask this to determine if retaliation is occuring.)
Yes
No
Clear selection
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