Bullying Report Form: Please help us by filling in all items on this form. Feel free to expand the 'Description' area below to type more than the single line shown.

Name of person being bullied(*)

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Name of Bully(*)

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Your Name (Optional)

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Please select a school(*)

South Dearborn High SchoolSouth Dearborn Middle SchoolAurora ElementaryDillsboro ElementaryManchester Elementary Invalid Input

When did the bullying happen?(*)

Calendar

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I am a(*)

Student
Parent/Guardian
Staff Member
Person Being Bullied
Community Member
Friend Invalid Input

Please select all that apply(*)

Physical - Hitting/kicking/other physical aggression.
Verbal - Teasing, name calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad.
Emotional/Exclusion - Starting rumors, telling others not to be friends with someone or other actions that would cause someone to be without friends.
Cyber-bullying - Using an electronic medium (including but not limited to: texts, e-mails, phone messages, facebook, etc.) to engage in any previously mentioned "bullying." Invalid Input

Description of Events (Please be specific - use exact wording, names, place, time, etc..)(*)

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Did you witness the bullying?

Yes
No Invalid Input

Please list the name of any other student or staff who may have witness the bullying

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Our school 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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