Bullying Prevention Report Form printable pdf download

Bullying Prevention Report Form

- Please print form, fill out and submit to Julia Jilek in the office.

Envelopes are available in the office if desired.

* = Required

Name of Reporter/Person Filling Out Report ________________________________________

(Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on

the basis of an anonymous report.)

Check whether you are the: *

Target of the behavior

Reporter (not the target)

Check whether you are a : *

Student

Staff Member

Parent

Administrator

Other: _________________________________

Your contact information/telephone number (optional): ______________________________________

Your School or Worksite: * __________________________________

Nature of bullying: *

(check all that apply)

Physical (persistent pushing/shoving, making threats, defacing property, stealing, etc.)

Emotional (persistent name calling, teasing, insulting, harassing phone calls, etc.)

Social (persistent gossiping, teasing about looks, excluding someone from groups, arranging public

humiliation, etc.)

Cyber (persistent texting/messaging threats, posting defamatory Web sites, e-mailing derogatory

photos, stalking etc.)

Name of student or Group of Students Targeted by Bullying Behavior: *

__________________________________________________________________________________

Person or Persons who are doing the Bullying: *

__________________________________________________________________________________

Date(s) of incident(s): ________________________________________________________________

Time when incident(s) occurred: ________________________________________________________

Location of incident(s): ________________________________________________________________

Bullying Prevention Report Form