EmailMe Form - Bullying/Harassment Report

Reporters Name (optional)
First Last
Today's date
MM / DD / YYYY
Email (optional)
Phone (optional)
### - ### - ####
Date of incident
MM / DD / YYYY
Name of school adult you have already contacted (if any):
First Last
Targeted Person's name (Required)
First Last
Names of individuals involved (if known):
Where did/does the bullying/harassment happen? (to select multiple options hold Ctrl)
If you selected other please describe:
Select the action that best describes what occured (to select multiple options hold Ctrl)
If you selected other please describe:
Why do you think the bullying/harassment occurred?
Were there any witnesses?
Yes
No
I don't know
If yes, please provide their names:
Did a physical injury result from the incident? If yes, please describe:
Was the target absent from school as a result of the incident?
Yes
No
I don't know
If yes, please describe:
Is there any other information?

Hitting, kicking, shoving, spitting, hair pulling or throwing something at the student
Getting anther person to hit or harm the student
Teasing, name calling, making critical comments or threatening in person, by phone, email etc
Putting the student down and making the student a target of jokes
Making rude and /or threatening gestures
excluding or rejecting
Making the student fearful, demanding money, or exploiting
Spreading harmful rumors or gossip
Cyber bullying (calling, texting, posting on any social media)
Other