Bullying Prevention Report Form
* 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)
Select your school or worksite
*
-
Area Learning Center
Birch Lake Elementary
Central Middle School
District Center
Hugo
Lakeaires Elementary
Lincoln Elementary
Matoska International
Normandy Park Education Center
Oneka Elementary
Otter Lake Elementary
Sunrise Middle School
Transition Plus
Vadnais Heights Elementary
WBLAS - North
WBLAS - South
Willow Lane Elementary
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, 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)
Graffiti
Notes
Email
Websites
Video/Audio Tape
Other:
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.
Name of Witness
(Person who saw the incident or have information about it):
Staff
Student
Other:
Name of Witness
(Person who saw the incident or have information about it):
Staff
Student
Other:
Name of Witness
(Person who saw the incident or have information about it):
Staff
Student
Other: