EmailMeForm
POCS Bullying Reporting Form
Please complete this form to report bullying or other incidents. This form is automatically forwarded to the Director and the Principal. You may remain 100% anonymous is you wish.
Describe what happened/what is happening?
Please be as detailed as possible.
When did the incident happen?
Before School
During School
After School
Unsure
Other
Date Time
MM
/
DD
/
YYYY
HH
:
MM
AM
PM
AM/PM
Where did it happen?
In the school building
Online
In the parking lot
On the bus
At a school event
Unsure
Other
Who was committing the bullying (if you don't know the bully's name(s) describe him/her?
Who was the victim of the bullying? (if you don't know his/her name, describe him/her)?
Did anyone else witness the bullying?
Yes
No
Unsure
If yes, please describe:
Were you or others physically hurt?
Yes
No
Unsure
If so, please explain:
Was there damage to anyone's personal property?
Yes
No
Unsure
If so, please explain:
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident?
Yes
No
Unsure
Please describe:
Have you ever told anyone about the bullying?
Yes
No
Please describe:
Have you previously filed a bullying report?
Yes
No
Describe:
**this information is used to determine if retaliation is occurring**
(Optional) Full Name
First
Last
Grade
7th
8th
9th
10th
11th
12th
(Optional) Phone
###
-
###
-
####
If not a student and would like a follow up call
(Optional) Email
File Upload
** Feel free to attach any documentation related to the incident **
