Homeroom Teacher
Your Name (Optional)
Date of Problem *

Select any of the following to describe the problem you are reporting:

Select all that apply: *
 A student being physically hurt by another student or several students. 
 A student being threatened by another student or several students. 
 A student being teased by another student or several students. 
 A student having a rumor or rumors spread about him/her. 
 Sexual comments or gestures made to a student. 
 A student having personal items taken or stolen.  
 A student or students purposely excluding another student. 
 A feeling of being bullied by an adult. 
 Other 
If Other, Please Explain:

Where did this situation occur, and be specific!

Location *
Time *
If during class, what class period?
If on the bus, what bus number?
Bus driver's name
Name of person/persons displaying inappropriate behavior
Is there anything else you would like to report?

This report will be given to the administrators, counselors and teachers who will then implement a plan to work with all the people involved, bullies and targets both.

IF FOR ANY REASON YOU FEEL IN DANGER OR BELIEVE ANYONE ELSE IS IN IMMEDIATE DANGER, PLEASE GO DIRECTLY TO THE PRINCIPAL OR COUNSELOR.