PJHS - Bullying / Threat Reporting Form Question Title * 1. Person(s) Reporting: (Please note that without providing your contact information, it may be difficult to pursue this report). Full Name: Phone Number: Email Address: Question Title * 2. The Person Submitting This Report Is: Reporter Student Student Reporter Student Witness Student Witness Reporter Parent/Guardian Parent/Guardian Reporter School Personnel School Personnel Reporter Other Other Reporter Question Title * 3. Type of Behavior - What did they do? Check All That Apply Cyber / Electronic Media (Internet website postings, chat rooms, videos) Cyber / Electronic Media (Internet website postings, chat rooms, videos) Check All That Apply Social (excluding, intimidation, telling lies/rumors, taunting) Social (excluding, intimidation, telling lies/rumors, taunting) Check All That Apply Physical (hitting, pushing, stealing, stalking) Physical (hitting, pushing, stealing, stalking) Check All That Apply Verbal (calling names, threatening, demeaning comments) Verbal (calling names, threatening, demeaning comments) Check All That Apply Question Title * 4. Who was being targeted or victimized? Question Title * 5. Witnesses - Who saw what happened? Question Title * 6. Describe, in as much detail as possible, the specifics of this ncident. Question Title * 7. Response - What did you do (if anything) in response to the incident? Question Title * 8. Please Specify the Location(s) - Where did it happen? Check All That Apply Classroom Classroom Check All That Apply Locker Room Locker Room Check All That Apply Hallway Hallway Check All That Apply Gymnasium Gymnasium Check All That Apply Lunchroom Lunchroom Check All That Apply Restroom Restroom Check All That Apply Recess Recess Check All That Apply On Bus / At Bus Stop On Bus / At Bus Stop Check All That Apply Text/Phone/Internet/Social Media Text/Phone/Internet/Social Media Check All That Apply Question Title * 9. Is this the FIRST time that an incident has occurred? Yes Yes No No Question Title * 10. Date and Time of Incident(s) - When did it happen? Incident #1 Date and Time: Date Time AM/PM - AM PM Incident #2 Date and Time: Date Time AM/PM - AM PM Incident #3 Date and Time Date Time AM/PM - AM PM Question Title * 11. Has this situation been reported to an adult? Yes Yes No No If so, to whom and when? Done
