STUDENT BULLYING REPORT FORM

Instructions: Please complete both pages, responding only to the questions that you feel comfortable answering and are able to accurately answer. You may choose to include your name at the bottom of the form or may submit it anonymously. Please note that the district’s ability investigate an anonymous complaint may be limited, and the District prohibits retaliation against anyone who files a bullying report.

Describe what happened/what is happening:
When did it happen?	Before school During school After school Unsure	Date: Time: am pm
Where did it happen?	In the school building (list specific room): On the school playground In the school parking lot On the school bus Online	At a school event (list specific event): Other (please specify): Unsure
Who was committing the bullying (if you don’t know the bully’s name(s) describe him/her?
Who was the victim of the bullying (if you don’t know his/her name, describe him/her)?
Did anyone else witness the bullying (if yes, please list)?	Yes No Unsure
Were you or others physically hurt (please explain)?	Yes No Unsure
Was there damage to anyone’s personal property?	Yes No Unsure
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)?	Yes No Unsure
Have you told anyone about the bullying?	Parent Babysitter Brother/sister Other family member:	Teacher Other school staff: Other:
Have you previously filed a bullying report (this information is used to determine if retaliation is occurring)? Yes No
Your name:
Your grade and age:
How can we contact you?	Phone: Email: Other:

Remember to hit “save” before closing this form. Please print the form and return it to any school staff member, the main office or place it in the bullying report drop box.