Bullying Form Generator Bullying Report Form Bullying Report Form You can file the report anonymously if you like. Since no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report, I strongly recommend that you do NOT report anonymously. Enter YOUR name, the name of the person filling out the form. You can submit an anonymous form, but there will be no consequence for the aggressor. I strongly recommend entering your name. Name: YOUR Name, the person filling out the form The TARGET is the person being bullied. Choose "Target" if YOU are being bullied or harassed. If you are reporting about someone else being bullied or harassed, you are the "Reporter" and should choose that option. Are you the TARGET of the bullying or just reporting it? Target Reporter Are YOU a: Parent Student Staff member Administrator Other If YOU are a student, what school: School YOU attend If YOU are a student, what grade are you in? If YOU are a staff member, what is your role? If YOU are an administrator, what is your title? If YOU chose "Other," please explain: Enter your telephone number and email address so that the school can get in touch with you. Although optional, I advise you to enter both. YOUR telephone number: YOUR email address: The "TARGET" is the person being bullied or harassed. It may be you, or the person who you are filling out the form for. Enter the name of the person being harassed or bullied. Name of the TARGET: Target's school: What is the name of the school that the person being bullied attends? Target's grade: What grade is the person being bullied in? What is the name of the accused bully? Name of AGGRESSOR: Aggressor's school: What is the name of the school that the accused bully attends? Aggressor's grade: What grade is the accused bully in? Date of the incident being reported or multiple dates for similar incidents Date (or dates) of incident(s): Where the bullying or harassment happened. One or several locations. Location of incidents(s): Making fun of someone's "disability" by teasing them about, calling them "stupid" or "retarded" or "lame" should be noted. I believe there may be DISABILITY issues involved. Disability Speaking of their race or color, using negative words about them should be noted. I believe there may be RACE or COLOR issues involved. Race/Color Teasing or bullying and using words like "fag," "dyke," "you do that like a girl," "gay," or in any way referencing sexual orientation is a civil rights issue. I believe there may be SEXUAL ORIENTATION issues involved. Sexual Orientation Harassment or bullying because of someone's gender is illegal. I believe there may be GENDER DISCRIMINATION involved. Gender Discrimination Making fun of someone's religion, religious practices or customs, religious clothing or jewelry is also a civil rights issue. I believe there may be RELIGIOUS DISCRIMINATION involved. Religion Harassment or bullying someone because of their age is also a civil rights issue. I believe there may be AGE DISCRIMINATION involved. Age This report has room for up to three witnesses. If there are more, add an additional sheet of paper. If there is at least one witness to the bullying or harassment, put that person's name here. Name of a witness: What is that witness? Student Staff Other Describe "other" Is there a second witness? Yes No If there is a second witness, add that person here. Name of a witness: What is that witness? Student Staff Other Describe "other" Is there a third witness? Yes No If there is a third witness, add them here. Name of a witness: If there is a third witness, add them here. What is that witness? Student Staff Other Describe "other" This is where you describe the incident or incidents. Give facts and quotes as necessary. If you need more room, you can add additional pages after printing out this form. Description of incident: If there was not enough room to enter all the information, you can continue it on a separate sheet of paper or on the back of the form after you print it. Check this box to let the school know that the description is continued. Is the description continued on another page? Yes, there will be more written Do you have other documentation that you believe will be helpful to the school but it is not on this form. It might be pictures, videos, screen shots, emails, etc. If you pick "Attached," you will attached those materials to the form you print out. Is there more documentation? None Attached Yes, but not attached This is a test to see that you are a real person! Simply click the box. reCAPTCHA By clicking on the "Submit" button, the data will be merged onto the proper form so you can give it to the school district. The form will download to your computer when you hit the Submit button. Once downloaded, you can open the report in Adobe Reader (or your browser) to edit, view, or print. You can then send the form to the school district. If you need help after submitting, Contact me. If you need Adobe Acrobat Reader DC (the odds are you don't), download here.