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Anonymous Bullying Report Form
Anonymous Bullying Report Form
Jones Brummett Elementary School
Date:
Answer required for "Date:"
Location of Incident:
Answer required for "Location of Incident:"
Hallway
Restroom
Classroom
Gym
Lunchroom
Playground
On Bus
After School Program
Text/Phone/Internet/Social Media
Other:
Name of Victim
*
Answer required for "Name of Victim"
Name of student being accused of bullying:
*
Answer required for "Name of student being accused of bullying:"
Individuals who may have witnessed incident:
Answer required for "Individuals who may have witnessed incident:"
Type of Bullying Behavior (Check all that apply)
*
Answer required for "Type of Bullying Behavior (Check all that apply)"
Shoved/Pushed
Hit, kicked, punched
Threatened
Stole/Damaged Possessions
Excluded
Taunting/Ridiculing
Writing/Graffiti
Told lies or false rumors
Staring/Leering
Intimidation/Extortion
Demeaning comments
Inappropriate touching
Cyber-bullying using text messages, website, email, or other technology
Other:
Reported By:
Answer required for "Reported By:"
Anonymous (I don't want to be identified)
Student
Parent
Teacher
Bystander
Name of person reporting (optional):
Answer required for "Name of person reporting (optional):"
Description of Incident:
*
Answer required for "Description of Incident:"
Confirmation Email
Confirmation Email
Answer required for "Confirmation Email"
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