JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Tri-County Special Education - Report Bullying
Use this form to report bullying you experienced or witnessed. Feel free to fill out as much or as little of this form as you feel comfortable with sharing. The more information you provide, the easier it will be to follow up on this behavior.
Sign in to Google
to save your progress.
Learn more
What happened?
Please indicate if the incident seemed to be motivated by one of these issues.
Your answer
Where did the bullying occur?
Was the bullying in the classroom, before school, in the hallways, at lunch, at home or online?
Your answer
What type of bullying happened?
Physical?
Verbal?
Social?
Electronic?
Other:
Clear selection
Was the bullying or harassment over one of these issues?
Please indicate if the incident seemed to be motivated by one of these issues.
Race
Sex
Religion
Other:
Clear selection
On what day did the bullying occur?
MM
/
DD
/
YYYY
At what time did the bullying occur?
Time
:
AM
PM
Was there physical injury?
Yes
No
Clear selection
Who was being bullied or harassed?
If you would like, let us know the names of the person(s) who were bullied or harassed? What grade and class are they in?
Your answer
Were there other witnesses?
Your answer
Is there any kind of proof?
Video/Audio Recording
E-Mail
Notes
Websites
Other:
Clear selection
Are you willing to share the proof?
(Photo, Email, Website, Social Media) Please paste a website link to proof if you can.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Tri-County Special Education JA.
Report Abuse
Forms
