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Instructions:

Please complete both pages, responding only to the questions that you feel comfortable answering and are able to accurately answer. You may choose to include your name at the bottom of the form or you may submit it anonymously.  Please note that the district’s ability to investigate an anonymous complaint may be limited, and the District prohibits retaliation against anyone who files a bullying report.

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* 1. Describe what happened/what is happening:

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* 2. When did it happen?

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* 3. Date and time this happened:

Date
Time

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* 4. Where did it happen?

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* 5. Who was committing the bullying (if you do not know the bully's name(s), describe him/her?

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* 6. Who was the victim of the bullying (if you don't know his/her name, describe him/her)?

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* 7. Did anyone else witness the bullying (if yes, please list)?

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* 8. Were you or others physically hurt (please explain)?

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* 9. Was there damage to anyone's personal property?

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* 10. Have you or the victim missed any school or made any changes to your daily routine as a result of the inciddent

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* 11. Have you told anyone about the bullying?

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* 12. Have you previously filed a bullying report (this information is used to determine if retaliation is occuring?

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* 13. Your name

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* 14. Your grade

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* 15. Your age:

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* 16. Best way to contact you-unless submitting anonymously.

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