Bullying Report Form

Bullying Report Form

Any student who believes he or she has been the target of unresolved, severe, or persistent harassment, intimidation or bullying, or any other person in the school community who observes or receives notice that a student has or may have been the target of unresolved, severe, or persistent harassment, intimidation or bullying may report incidents through this link. All school staff must report reports of bulling to school principal via email.
All answers are confidential and will only be shared with school administration, so proper safety steps can be taken. If you are completing this report because someone other than yourself is being bullied, please provide the information for that person.
Name

First NameLast Name
What is your date of birth?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What school do you attend?
What is your grade?
Where did the bullying incident happen?

Other
When did the bullying incident happen?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please select your experience.

Other
Please tell us about the bullying incident.
Would you like to have a counselor reach out to you?
IF YES, PLEASE PROVIDE YOUR NAME AND PHONE NUMBER BELOW.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: