Bullying Report Form

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Reporting bullying or harassing behavior is the first step toward making our schools a safe place for everyone. Please report bullying if you are experiencing it, or witness it in school, on the bus, at school events, or online.

Use the following form to report bullying. Fill it out online and it will be submitted directly to the administration staff of the school. Reports are held in the strictest of confidence.

Whether you are a witness or target in this case, we want to thank you for helping us maintain a positive and safe school environment for all of our students. (All names provided are kept confidential.)

Today's Date *

YYYY

Your Name (This is not required, but would be appreciated. This report will be kept confidential and your identity will remain anonymous):

When did the bullying occur? *

(Please tell us the date it happened):

YYYY

Where did this happen? *

(For example, the bus stop, the cafeteria, on the internet, etc.):

Name of Bully(ies): *

Name of Target(s): *

Describe what happened as clearly as possible with as many details as you can remember: *

Were there any witnesses? *

(If yes, please list their names, if you know it, or a description):

Did you report this to anyone? *

(If yes, please tell us who. For example, a policeman, parent, teacher, etc):

Please choose the grade level: *

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