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Student Bullying Report Form
Please fill out the necessary fields. Respond only to questions that you feel comfortable answering and are able to accurately answer.
You may choose to include your name at the end of the form or may submit it anonymously.
Please note that the district's ability to investigate an anonymous complaint may be limited, and the District prohibits retaliation against anyone who files a bullying report.
Describe what happened / what is happening:
When did it happen?
Before school
During school
After school
Unsure
Date
Time
Where did it happen?
School building (list specific room)
On the playground
In the school parking lot
On the school bus
Online
At a school event (list specific event)
Other (please specify)
Unsure
Area or room in school
School Event
Other (please specify)
Who was committing the bullying (if you don't know the bully's name(s) describe him/her?
Who was the victim of the bullying (if you don't know his/her name, describe him/her?
Did anyone else witness the bullying (if yes, please list)?
Yes
No
Unsure
Individuals witnessing the bullying
Were you or others physically hurt (please explain)?
Yes
No
Unsure
Explanation of physical injury
Was there damage to anyone's personal property?
Yes
No
Unsure
Description of damage done
Have you missed or the victim missed any school or made any changes to your daily routine as a result of the incidents(s)?
Yes
No
Unsure
If yes, please explain
Have you told anyone about the bullying? (you may check more than one)
Parent
Babysitter
Brother / Sister
Other family member
Teacher
Other school staff
Other
Who did you notify? List the name(s) of those individuals that you have notified.
Have you previously filed a bullying report (this information is used to determine if retaliation is occurring)?
Yes
No
Your Name - please give both first and last name
Your grade and age
Phone number
Email adress
Other
Send this form to the following:
*
Mary Beth Pilon, Gr. PreK-4 Counselor
Lyndsy Lynch, Elementary Principal
Candace Kornelsen, Gr. 5-8 Counselor
Lisa Narum, MS Principal
Trista Ziegelmann, Gr. 9-12 Counselor
Nikki Wixo, Academic Dean & HS Principal
Travis Lemar, Activities Director
Morgan Forness, Superintendent