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Vernon ISD Report a Bully
The form is a way for anonymous reports of bullying to be filed.
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* Indicates required question
Date of Incident:
*
MM
/
DD
/
YYYY
Time of Incident:
*
Time
:
AM
PM
Repeat Infraction?
*
Yes
No
Name(s) of Victim(s):
*
Your answer
Name(s) of Student(s) bullying:
*
Your answer
Name(s) of witness or bystander(s):
*
Your answer
Type of Bullying:
*
Verbal
Physical
Relational
Bullying Behaviors (check all that apply):
*
Shoved/Pushed
Excluded
Staring/Leering
Cyberbullying
Racial
Sexual
Religious
Disability
Hit, Kicked, Punched
Taunting/Ridiculing
Intimidation/Extortion
Threatened
Writing/Graffiti
Demeaning Comments
Stole/Damaged Possessions
Told Lies or False Rumors
Inappropriate touching
Other:
Required
Reported to school by (check all that apply):
*
Teacher
Student
Bystander
Victim/Target
Parent
Bus Driver
Anonymous
Other
Required
Describe the incident:
*
Your answer
Physical Evidence?
*
Notes
Email
Graffiti
Voice/Audio
Website
Other
Submit
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This form was created inside of Vernon Independent School District.
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