Elementary Bully Report Form

This form may be used by anyone who experiences or witnesses bullying of a North Judson-San Pierre Elementary School student. Fill the form out fully and hit the SUBMIT button to turn it into the elementary school principal.

Date(*)

Please select a date.

Your Name

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Did you witness the bullying?(*)

Yes No

Please specify yes or no.

I am a
(*)

Name of person being bullied(*)

Please enter the name of the person being bullied.

Enter name of bully and their grade/school (if known). If there was more than one bully, add their names here too.

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Where did this take place?

If you selected classroom, please identify which room.

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Type of Bullying
(Select all that apply)(*)

Description of events
(Please be specific - use exact wording, names, dates, location and time, etc.):(*)

Please describe the event.

Why did the bullying happen?(*)

Please describe the event.

What has been done to help stop the bullying?(*)

Told the person to stop
Moved away from the person
Ignored the situation or did nothing
Tried to make a joke of it; laughed it off
Tried to talk to the person
Told an Adult

Please choose one or more of the following.

Please list other students/staff who may have witnessed the bullying incident described above:

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Please use this space to tell us anything else about the bullying.

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The administrators will investigate the report and take appropriate actions to deal with the situation. Since much of what we do needs to remain confidential, you may not know of the steps we take to stop the bullying. If the bullying does not stop, we need to take additional steps. Please let us know if the bullying continues.

Human Verification(*)

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North Judson-San Pierre Schools

Elementary Bully Reporting Form