Bullying Report Form
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1
. Who is the target of the bullying behavior?
Who is the target of the bullying behavior?
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2
. Who is/are the student(s) engaging in bullying behaviors?
Who is/are the student(s) engaging in bullying behaviors?
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3
. Where did this incident take place?
Where did this incident take place?
In School
In the cafeteria
On the bus
Online (Facebook, IM, Text Message, etc)
In the gymnasium
At the lockers
In the restroom
After School event
Before School event
Other (please specify)
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4
. Is this bullying behavior ...
Is this bullying behavior ...
Verbal
Physical
Cyber (online)
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5
. Does the student exhibiting bullying behavior act this way with other students or was this an isolated incident?
Does the student exhibiting bullying behavior act this way with other students or was this an isolated incident?
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6
. Have you talked to any adults about this before reporting what happened to Mrs. Fisher? If so, which adult and when did you report it?
Have you talked to any adults about this before reporting what happened to Mrs. Fisher? If so, which adult and when did you report it?
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7
. You can remain anonymous or submit your name confidentially so that Mrs. Fisher can discreetly find time to meet with you to discuss this matter further. Please submit your name or type Anonymous.
You can remain anonymous or submit your name confidentially so that Mrs. Fisher can discreetly find time to meet with you to discuss this matter further. Please submit your name or type Anonymous.
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