South Spencer School Corporation Bullying Form

Please complete all of the areas below that you can. Information that is (*) starred is required. Thank you.

Who Are You?

Person Reporting Bullying (First Name and Last Name)(*)

Please let us know your name.

What is Today's Date(*)

Select ...

Please select today's date.

When did the bullying happen?(*)

Tell us when it happened.

Who Was Bullied?

Who do you think was bullied? (First Name and Last Name)(*)

Please let us know the bully's name.

Where does this person attend school?

Select A School ...South Spencer High SchoolSouth Spencer Middle SchoolLuce Elementary SchoolRockport Elementary School Invalid Input

Who is this person's teacher?

Please write a subject for your message.

What grade?

Who Is The Bully (or Bullies)?

Who do you think was bullying?(*)

Please let us know the person's name.

What grade?

Please let us know your name.

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) Select one type.

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 Tell us where the bullying happened.

Other Information

Is this the first time that this has happened?(*)

Yes No Please answer this question.

Have you filed a Student Bullying Report before?(*)

Yes No Please answer this question.

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 Please tell us this.

Any other information that you would like to share?

Human Verification(*)

Invalid Input