Bullying Survey

Bully Reporting Form

Please use this for to report bullying for the JR/SR High School

Where did the incident occur?

When did it happen?

How many times has this situation happened?

Have you reported this to an adult?

Who was bullying, harassing, intimidating or causing harm?

Who was the person being harmed, bullied, harassed or intimidated?

Describe what happened. Give as much information as you can. Let us know if there were any witnesses.

Who are you?

What is your name? (optional)

If you would like someone to contact you, please add your email or phone number here.

What School?

To validate your submission, please answer the following math problem: