Taylor Student Bully Report
Please complete all areas of this form to report a bullying incident.
Let's start with your name
Your name
*
First Name
Last Name
Date the incident happened
*
-
Month
-
Day
Year
Date
Who was Bullied?
Victim's name
*
First Name
Last Name
What school does victim attend?
*
Taylor High School
Taylor Middle School
Taylor Elementary School
Other
Victim's grade level?
12
11
10
9
8
7
6
5
4
3
2
1
Kindergarten
Don't Know
Who are the Bullies?
Bully's name
*
First Name
Last Name
Bully's grade level?
12
11
10
9
8
7
6
5
4
3
2
1
Kindergarten
Don't Know
Was there more than one bully?
*
Yes
No
I don't know
Tell us about the Incident
Type of bullying (check all that apply)
*
Called mean names
Excluded (left out)
Took or damaged something
Threatened
Hit, kicked, punched
Told lies/spread rumors
Cyber-bullying (online/eMail/text, etc.)
Racial/offensive Comments (talking)
Where did the bullying happen? (check all that apply)
*
Hallway
Cafeteria
On the Bus
Bus Stop
Classroom
Playground
Bathroom
Going to/from school
Online/eMail/text
Is this the first time that this has happened?
*
Yes
No
Have you filed a Student Bullying Report before?
*
Yes
No
Who has been told about the bullying or saw what happened? (check all that apply)
*
Teacher
Principal
Friend
Parent/Guardian
Assistant Principal
Students
Counselor
Nobody Yet
Any other information that you would like to share?
Submit
Should be Empty: