Brevard Public Schools Bullying Or Harassment Reporting Form Elementary School
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1Brevard Public Schools
Bullying or Harassment Reporting Form
Elementary School
A student can report bullying or harassment by talking to an adult at school or completing this
form and returning it to an. assistant principal or principal. A student can place this form in the
school's drop off spot for anonymous reporting.
PLEASE PRINT
Write your name if you want to: _______________________________________________________
Write down your school: _____________________________________________________________
Write down who is the bully or bullies: __________________________________________________
_________________________________________________________________________________
Tell how many times the bullying has happened:
1 time
2 times
3-5 times
More than 5 times
Tell where it happened:
In the classroom
At recess
In the lunchroom
In the hall
On a school bus
On the way to/from school
At the bus stop
Other _______
Tell what happened:
Teasing
Hitting or kicking
Gossip and rumors being spread
Made fun of
Name calling
Shoving or pushing
Cyber bullying
Other _____
What did the bully/bullies say or do? ___________________________________________________
You can sign this form if you want to: ___________________________________________________
Date: ____________________________________________________________________________
Thank you. This report will be looked in to. If you think a student is in danger, please contact a trusted adult right
away!
For Office Use Only
Date Received:
Received by:
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