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ESSER III
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Bullying Report Form
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.
Answer required for "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."
Cedar Hill
Prichard
Scyene
Contact Information
Name of Person Submitting Report (NOT REQUIRED) AND GRADE LEVEL
Answer required for "Name of Person Submitting Report (NOT REQUIRED) AND GRADE LEVEL"
Name of Potential Victim and grade level
*
Answer required for "Name of Potential Victim and grade level"
Name of Potential Bully and grade level
*
Answer required for "Name of Potential Bully and grade level"
Name of Witness and grade level
*
Answer required for "Name of Witness and grade level"
Date of Incident
*
Answer required for "Date of Incident"
Time
*
Answer required for "Time"
Location of Incident:
*
Answer required for "Location of Incident:"
What Happened? Describe what happened: (Additional information may be attached to support this form)
*
Answer required for "What Happened? Describe what happened: (Additional information may be attached to support this form)"
Please tell us if physical force or threats were used, or if cyber bullying was involved. Please describe
*
Answer required for "Please tell us if physical force or threats were used, or if cyber bullying was involved. Please describe"
What did the potential victim do?
*
Answer required for "What did the potential victim do?"
Was anyone else involved? If so, who?
*
Answer required for "Was anyone else involved? If so, who?"
Were there any witnesses? If so, who?
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How often has this happened?
*
Answer required for "How often has this happened?"
Describe what happened immediately before the incident?
*
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Have you previously reported this to anyone? If so, who?
*
Answer required for "Have you previously reported this to anyone? If so, who?"
Confirmation Email
Confirmation Email
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