Loading...

Editing previous response:

Please fix the highlighted areas below before submitting.

Bullying Report Form

Please complete the form below. Required fields marked with an asterisk *
Contact Information
Address
State*
Answer Required

Incident Information

Location of Incident*
Please select your school.
Answer Required
Please select where the incident happened?
Answer Required
Your role?*
Please tell us who you are?
Answer Required

Types of Harassment, Intimidation and Bullying

  • Physical involves hurting a person’s body or possessions. Physical includes:
    • Hitting/kicking/pinching
    • Spitting
    • Tripping/pushing
    • Taking or breaking someone’s things
    • Making mean or rude hand gestures
  • Verbal is saying or writing mean things. Verbal includes:
    • Teasing
    • Name-calling
    • Inappropriate sexual comments
    • Taunting
    • Threatening to cause harm
  • Social, sometimes referred to as relational, involves hurting someone’s reputation or relationships. Social includes:
    • Leaving someone out on purpose
    • Telling other children not to be friends with someone
    • Spreading rumors about someone
    • Embarrassing someone in public
  • Cyberbullying is bullying that takes place using electronic technology. Examples of cyberbullying include:
    • Mean text messages or emails
    • Rumors sent by email or posted on social networking sites
    • Embarrassing pictures, videos, websites, or fake profiles
More information at stopbullying.gov
Cause of harassment, intimidation, bullying or harm:
Answer Required
Method of harassment, intimidation, bullying or harm:
Answer Required
Who was harassing, intimidating, bullying or causing harm?
Answer Required

By submitting this form you acknowledge that the information entered is complete, true, and accurate. Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.

By checking this box you agree to the above disclaimer.*
Answer Required
Confirmation Email