Student Bullying/Harassment Reporting Form

BREVARD PUBLIC SCHOOLS 

STUDENT REPORTING FORM 

For a report of student-related bullying, sexual harassment, other forms of harassment, and teen dating violence and abuse. This form is to be confidentially maintained in accordance with the Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. § 1232g. 

A student can report bullying or harassment by talking to an adult at school or completing this form and returning it to the dean, assistant principal, or principal. A parent can place this form in the school’s drop off spot for anonymous reporting. 

Today’s Date 

____/____/_____

School

______________________________________________________

Your Name 

______________________________________________________
(Please print) 

Were you an eye witness? 

No         Yes 

If no, who reported it to you? 

______________________________________________________

Who does this involve?

______________________________________________________

What happened?

Choose all that apply and describe the exact words or behaviors used under "Other" 

Teasing Hitting or kicking

Gossip and rumors being spread

  • Taunting
  • Name calling
  • Being left out on purpose
  • Made fun of
  • Getting someone in trouble

E-mail, Facebook®, text message  (Print all messages and attach)

Shoving or pushing

Other (specify) ______________________________________________________

Describe what happened (the most recent incident)

______________________________________________________
(attach a separate sheet, if necessary) 

When did this happen?
Date:
______________________________________________________ 

Where did this happen?

On school property – (if you circle this, list the location at school ______________________________________________________

On a school bus at school-sponsored activity or event off school property?

On the way to / from school?

Other ______________________________________________________

What have you done to try to stop his/her behavior? 

______________________________________________________

Is there anyone who witnessed this behavior? 

______________________________________________________

How has this incident affected you?

______________________________________________________

Have you reported prior problems with this student(s) to a teacher, principal, or other school staff before? 

No       

Yes (If yes, who did you report it to?) ______________________________________________________

How many times have issues come up with the same student(s) before this incident? 

Check most appropriate number of Incidents. 

 ____One (1)       ___Two (2)       ___Three or more (3 or more) 

Describe the details of any other incident below. 

Describe what happened  (the second incident)

______________________________________________________

When did this happen? Date:
______________________________________________________

Whom did it involve?______________________________________________________

Was there anyone who witnessed this behavior?

______________________________________________________

Where did this happen? 

On school property – (if so, list the location at school) ______________________________________________________

On a school bus?

At school-sponsored activity or event off school property?

On the way to / from school?

Other
______________________________________________________ 

Did you report the problem to a teacher, principal, or other school staff? 

No         
Yes  (If yes, who did you report it to?) ______________________________________________________ 

What did they do to help?

______________________________________________________

Additional incident prior to the above incident: 

Describe what happened (the third incident)

______________________________________________________

When did this happen?
Date:__________________________________________________

Whom did it involve? 

______________________________________________________

Was there anyone who witnessed this behavior?

______________________________________________________

Where did this happen? 

On school property – (list the location at school) ______________________________________________________

On a school bus

At school-sponsored activity or event off school property

On the way to / from school

Other__________________________________________________

Did you report the problem to a teacher, principal, or other school staff? 

No

Yes   (If yes, who did you report it to?) ______________________________________________________

What did they do to help?

______________________________________________________

What would you like us to do to help?

______________________________________________________

*You may list any other prior incidents on a separate sheet of paper then attach to this form.

______________________________________________________ ____/____/_____

 

Your Signature  
Date

Thank you. This report will be investigated.

If you think you are in danger, please contact a trusted adult right away! 

………………………………………………………………………................................................................................................................................

FOR ADMINISTRATOR USE ONLY

Date Received: _________________________________________

Received By: ___________________________________________

Administrative Findings: 
_____ No further action required.
_____Further investigation required.
(Incident Investigation Form 4) 

Rev. 7/12 VS/PF/BT Student Services 

This report must be attached to Incident Investigation Form 4