Bullying Incident Form
If you have information regarding  bullying and would like to report this information anonymously, please fill out the following form to the best of your knowledge.  Please note that this form is completely anonymous, unless you provide your name.

For purposes of this form, bullying encompasses harassment and discrimination and means doing, saying or acting in a way that hurts someone else or makes him or her feel bad intentionally.  Bullying may consist of the following types of behavior: verbal bullying (name-calling); physical bullying (punching, pushing); social bullying (leaving someone out of a game or group on purpose); extortion (stealing someone’s money) and cyber-bullying  (using e-mail, instant messaging, the Internet, mobile phones, etc. to bully others).
Sign in to Google to save your progress. Learn more
Your Name (First & Last):  Students have the right to complete this form anonymously. However, it will be easier for the District to investigate this matter if as much information as possible is provided. Submission of a good faith complaint or report of bullying will not affect the reporter's future employment, grades, learning or working environment. A false complaint will be subject to disciplinary action.
Are you a: *
Name of student(s) being bullied or harassed (THE VICTIM): *
Which building does the VICTIM attend? * *
Person(s) accused of bullying or harassment (THE BULLY) : *
Which school does the BULLY attend? *
Date(s) of alleged bullying or harassment (WHEN?): *
Location(s) of alleged bullying or harassment (WHERE?): *
Please describe in as much detail as possible what happened? *
Were there any other persons who may have witnessed the bullying or harassment? *
If yes, please name them and provide as much detail as possible about these witnesses and what they may have seen? (List your name if you would like to be contacted.)
Have you reported this to anyone else? * *
If so, who have you reported this to?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Marion County R-II. Report Abuse
Google Forms