Bullying/Harassment Form
Mid Prairie Bully Report Form
Report of a Bullying/Harassment Incident
Bullying is when a stronger, more powerful person hurts or frightens a smaller weaker person, on purpose, again and again.
Directions: Please answer these questions as honestly and specifically as you can.
The situation will be handled as confidentially as possible.
Return this completed form to the office.
Person Reporting: ___________________________ Grade: ______ Date: ____________
If person reporting is the witness, who is being bullied/harassed?
___________________________________________________________ Grade: ______
1.Who is harassing/bullying you? ____________________________________________________________
2.What has happened? ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3.Where did it happen? ________________________________________________________________________
4.Witness/es name/s (if any): ____________________________________Grade: ______
5.How long has this been going on? _____________________________________________________________________
6.What have you done about this problem? ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
7.Have you talked to anyone about this already? ?
(Student, Teacher, Other Adult) Yes No _____________________Who do you want to talk to about the problem? __________________________________
8.What do you want to happen now?
_____ I just want someone to know.
_____ I want an adult to talk to the person who is harassing/bullying me.
_____ I want an adult to help me and the person/s doing the harassing/bullying to solve the problem.
_____ I want an adult to try to stop the bullying/harassment.
******************************PRINCIPAL/STAFF FOLLOW UP*******************************
______________Date I met with reporting student.
______________ Date I followed up with person/s doing the harassing.
______________ Date I followed up with reporting student.
X ____________________________________________ _________________
Principal/Staff Signature Date
A staff person has met with me about the resolution of this incident.
X_____________________________________________ __________________
Reporting Student Signature Date
This report and follow-up will be kept on file in the office and entered on
Power School to provide a cumulative record.
Log of follow up on this incident:
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Consequence Component:
q None, this was a false allegation
q Student conference
q Student warning
q Letter of apology
q Mediation
q Counseling
q Parent letter
q Parent phone call
q Parent conference
q Detention
q In-school suspension
q Out-of-school suspension/expulsion
q Board hearing
q Other (specify) ______________________________
Social Learning Component:
Restitution / Restorative Component:
________Date/initial filed and entered on PowerSchool under the behavioral log entry.
________Date/initial if this is a report of sexual harassment
________Date/initial if this is a report involving a school employee