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