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Anonymous Bullying Report Form
Anonymous Bullying Report Form
Sam Houston Elementary School
Date:
Answer Required
Location of Incident
Answer Required
Hallway
Restroom
Classroom
Gym
Lunchroom
Playground
On Bus
After School Program
Text/Phone/Internet/Social Media
Other:
Name of Victim
*
Answer Required
Name of student being accused of bullying
*
Answer Required
Individuals who may have witnessed incident:
Answer Required
Type of Bullying Behavior (Check all that apply)
*
Answer Required
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
Anonymous (I don't want to be identified)
Student
Parent
Teacher
Bystander
Name of Person Reporting (optional)
Answer Required
Description of Incident:
*
Answer Required
Confirmation Email
Confirmation Email
Email Required
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