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.

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.
School YOU attend

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.

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.
What is the name of the school that the person being bullied attends?
What grade is the person being bullied in?
What is the name of the accused bully?
What is the name of the school that the accused bully attends?
What grade is the accused bully in?
Date of the incident being reported or multiple dates for similar incidents
Where the bullying or harassment happened. One or several locations.
I believe there may be DISABILITY issues involved.
I believe there may be RACE or COLOR issues involved.
I believe there may be SEXUAL ORIENTATION issues involved.
I believe there may be GENDER DISCRIMINATION involved.
I believe there may be RELIGIOUS DISCRIMINATION involved.
I believe there may be AGE DISCRIMINATION involved.
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.
If there is a second witness, add that person here.
If there is a third witness, add them here.
If there is a third witness, add them here.
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.
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.
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.
This is a test to see that you are a real person! Simply click the box.

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.

Sending

If you need help after submitting, Contact me.

If you need Adobe Acrobat Reader DC (the odds are you don't), download here.