GFPS Staff Bullying Report Form

Student Bullying Report Form

Grand Forks Public Schools
Instructions: Please respond only to the questions that you feel comfortable answering and are able to accurately answer. You may choose to add your name at the end of the form or may submit it anonymously. Please note that the district's ability to investigate an anonymous complaint may be limited, and the District prohibits retaliation against anyone who files a bullying report.
Describe what happened/what is happening:*
When did it happen?*

Before schoolDuring schoolAfter SchoolUnsure
Date*

MonthDayYear
Date
Time*
Where did it happen?*

In the school buildingOn the school playgroundIn the school parking lotOn the school busOnlineAt a school eventUnsureOther
Add any details for the instances noted above.*
Who was committing the bullying (if you're unsure of the bully's name(s) describe them)?*
Who was the victim of the bullying (if you're unsure of their name, describe them)?*
Did anyone else witness the bullying?*

Yes (list below)NoUnsure
Please list names of witnesses.*
Were you or others physically hurt?*

Yes (explain below)NoUnsure
Please explain who was physically hurt.*
Was there damage to anyone's personal property?*

Yes (describe below)NoUnsure
Please describe the damage to personal property.*
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)?*

Yes (explain below)NoUncertain
Please describe their change in routine.*
Have you told anyone about the bullying?*

ParentBabysitterBrother/SisterTeacherOther school staffOther family memberOther
Have you previously filed a bullying report (this information is used to determine if retaliation is occurring)?*

YesNo
Your name*

First NameLast Name
Your grade*
Your age*
Your school*
How may we contact you? (phone number or email address)*
Should be Empty:

Student Bullying Report Form