Report Bullying Now

1.	Have you reported this incident to anyone in authority? This could include a teacher, principal, or any other staff member at the school.*
	Have you reported this incident to anyone in authority? This could include a teacher, principal, or any other staff member at the school.* Yes No

2.	If you answered "Yes," who did you tell?*

3.	Name of person you believe is being bullied or harassed. (First and last name if known.)*

4.	Which school?*
	--Please Select--Belmont ElementaryClear Creek ElementaryHorizon ElementaryMize ElementaryPrairie Ridge ElementaryRiverview ElementaryStarside ElementaryLexington Trails Middle SchoolMill Creek Middle SchoolMonticello Trails Middle SchoolDe Soto High SchoolMill Valley High School

5.	Where, exactly, did the bullying take place? Be as specific as possible regarding the incident(s).*

6.	What happened? (Check all that may apply.)
	Physical: hitting, kicking, or other physical aggression    Verbal: teasing, name-calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad    Exclusion: starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends    Cyber bullying: using a computer, mobile phone, or other electronic device to engage in any previously mentioned bullying    Other, please specify

7.	Name of the alleged bully

8.	Please describe the incident.*

9.	Date of the incident?

10.	Did you witness the event?*
	--Please Select--Yes No

11.	Please list others who may have witnessed the incident.

12.	Your name (optional)

13.	I am...
	--None--the person being bullieda studenta parent / guardiana school employeea friend

14.	Additional comments