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See It, Say It! Form
Village East Elementary
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Date of Report
*
MM
/
DD
/
YYYY
Who is causing a problem for you, or others?
*
Your answer
What did the person/people do?
*
Tease/use mean words
Threaten to hurt/fight
Hit, Punch, Kick, Etc.
Spread Rumors
Cyberbully
Other
Required
Where did the problem occur?
*
Bus stop/bus ride
Recess
Hallway
Classroom
Cafeteria
Bathroom
Internet/cell phone
Other:
Required
Tell me exactly what happened.
*
Your answer
List the names of anyone who saw this happen.
Your answer
Did you, or anyone else, tell this person to STOP?
*
Yes
No
Has this person/people been a problem for you or others in the past?
*
Yes
No
For office use only:
Teacher:
Counselor:
Principal:
For office use only:
DECISION/ACTION TAKEN
Your answer
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