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:

Notes of interview with reporter:

Note of interview with person/s reported to doing the harassing/bullying:

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