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 : *

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): ________________________________________________________________

Physical Evidence:

(Check all that apply)

Describe the details of the incident *

(Including names of people involved, what occurred, and what each person did and said, including specific words used).

Please use as much space as necessary.)

__________________________________________________________________________________________________

_________________________________________________________________________________________________

(use back of paper if more space needed)

Name of Witness (person who saw the incident or have information about it):

_________________________________________________________________________________

Name of Witness (person who saw the incident or have information about it):

_________________________________________________________________________________

Name of Witness (person who saw the incident or have information about it):

_________________________________________________________________________________