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Bullying Report Form

Potential Bullying Report Form

Note to Person Reporting: This form will be confidentially maintained in accordance with the Family Educational rights and Privacy Act ("FERPA"), and generally will not be shared with anyone except those working to investigate or respond to the report. It's NOT MANDATORY to provide your name when completing this report. Please return completed forms to any campus Main office. Anonymous forms may be place in a sealed envelope and given to campus Principal or designee.

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Cedar Hill

Prichard

Scyene

Contact Information

Name of Person Submitting Report (NOT REQUIRED) AND GRADE LEVEL

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Name of Potential Victim and grade level*

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Name of Potential Bully and grade level*

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Name of Witness and grade level*

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Date of Incident*

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Time*

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Location of Incident:*

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What Happened? Describe what happened: (Additional information may be attached to support this form)*

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Please tell us if physical force or threats were used, or if cyber bullying was involved. Please describe*

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What did the potential victim do?*

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Was anyone else involved? If so, who?*

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Were there any witnesses? If so, who?*

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How often has this happened?*

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Describe what happened immediately before the incident?*

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Have you previously reported this to anyone? If so, who?*

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