EmailMeForm
Name of Student Target (victim)
*
Has the appropriate teacher/coach/bus driver been contacted?
Yes
No
If yes, please provide the name(s) of who you contacted:
Name(s) of alledged bully(ies) (if known):
On what date(s) did the incident happen?
*
Where did the incident happen? Please choose all that apply:
*
Classroom
Hallway
Restroom
Playground
Locker Room
Lunchroom
Parking Lot
School Bus
Internet
Cell Phone
At a school sponsored activity or event off school property
On the way to/from school
Other
If you selected other, please specify
Please select the statement(s) that best describe what happened. Please choose all that apply:
*
Hitting, kicking, shoving, spitting, hair pulling or throwing something
Getting another person to hit or harm the student
Teasing, name calling, making critical remarks or threatening, in person or by other means
Demeaning and making the victim of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Intimidating (bullying), extorting or exploiting
Spreading harmful rumors or gossip
Cyberbullying
Other
If you selected other, please specify:
What did the alleged bully(ies) say or do?
*
Why did the harassment or intimidation (bullying) occur?
*
Were there any witnesses?
Yes
No
Don't Know
If yes, please provide their names:
Did a physical injury result from this incident?
Yes
No
If yes, please describe:
Was the victim absent from school as a result of the incident?
Yes
No
If yes, please describe:
Is there any additional information you would like to provide?
Name of person reporting (optional)
Today's date:
Email (optional)
Phone number (optional)
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