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5312.4-E.4, Confidential Report Form

Please use this form to report incidents of bullying which you believe are occurring in our school. The information that you share will NOT be shared with other students. By helping us know what to look for, adults can be “assigned” to place where bullying occurs and reduce the chances that bullying will happen.

  1. What is your role?
    _____ student
    _____ staff member
    _____ parent

  2. If this is an elementary complaint, which is your school?
    _____ Blue Creek
    _____ Boght Hills
    _____ Forts Ferry
    _____ Latham Ridge
    _____ Loudonville
    _____ Southgate

  3. If this is a junior high complaint, which is your hall?
    _____ Calhoun
    _____ Clay
    _____ Houston
    _____ Norris

  4. If this is a high school complaint, which is your hall?
    _____ LaFollette
    _____ Taft

  5. If possible, please give the name of the student(s) who you believe is bullying others. If you don’t know, please indicate “don’t know”:

  6. Please describe the bullying actions you have witnessed by the person named in question #5:

  7. How would you categorize such actions?
    _____ irritating
    _____ embarrassing
    _____ worrying
    _____ frightening
    _____ alarming

  8. Where are you witnessing the bullying? Please be as specific as possible. For example, “In the hallway between the library and the cafeteria”:

  9. When are you witnessing this behavior? Please list all the different times if this occurs throughout the school day. For example, “Right after the last lunch”:

  10. Would you like to give us your name? (Without a way to verify or gather further information about this complaint, we may not be able to address or investigate the situation as fully as possible.) We will not reveal your name to students.


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