EmailMeForm
Beardstown Bullying Report Form
Report incidents of bullying here. Reports are anonymous.
Date Time
MM
/
DD
/
YYYY
Name (Optional)
First
Last
Alleged Student Bully(ies)
Alleged Student Bully(ies)
Alleged Student Bully(ies)
Alleged Student Target(s)
Alleged Student Target(s)
Alleged Student Target(s)
Describe the events that have occurred.
How long has this been happening? Be Specific.
When and where is this happening? (bus stop, cafeteria, locker room, etc.)
What did you do when it happened? List the ways you have responded (if any).
Witnesses (adults or students) who might have observed the incident(s).
Who have you reported this to?
Nobody
Administration
Parents
Bus Driver
Counselor
Teacher
Other
Name of person you reported this to (if any):
What would you like for an adult to do to help you? (Example: listen to me, talk to the students, watch for similar behavior, etc.)
Do you want an intervention for this incident?
Yes
No
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