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Bullying Report Form
Use this CONFIDENTIAL form to report bullying or harassment behaviors. We will respond within 24 hours using the email address you provide.
1. First Name (Optional)
2. Last Name (Optional)
3. Email
4. Name of Victim (Person being bullied)
5. Name of Perpetrator (Person who is bullying)
6. Where/when are the bullying behaviors happening?
On the way to school
During Recess
During Lunch
In the classroom
On the way home from school
Evenings/weekends while out of school
Other (Specify in Question 9)
Select at least 1.
7. What type of bullying/harassment behaviors are happening?
Verbal (Name calling/teasing)
Physical (pushing, hitting, kicking)
Indirect (Spreading rumors)
Cyberspace (Facebook or Twitter)
Cell Phone (Texting or pictures)
Other (Specify in Question 9)
Select at least 1.
8. Have you told anyone about these bullying behaviors?
An adult at home
An adult at school
A friend
I haven't told anyone
Other (Specify in Question 9)
Select at least 1.
9. What other information or details would you like us to know?
Submit
Thanks for submitting!
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