I am a: *- Select -StudentParentFamily member
During this incident I was a: *- Select -VictimBystander
What is your name? (optional) If you believe this person should receive consequences for their actions beyond a conversation, we need to know the name of the person reporting. Your name can be kept confidential and will not be released to the person you are reporting if you are not comfortable.
What grade are you in? 6 7 8
What is the name of the student you would like to report? * If you do not know the name of the student, please describe the person.
Where did this incident take place? *- Select -In classOn campusLunch QuadOnline (cyberbullying)Off campusPE locker roomOther
Please describe the incident. *
Were there witnesses to this incident? * Yes No
What are the names of the witnesses?
Please rate the severity of this incident from your perspective, 1 being minor incident but unacceptable to 5 being major incident, could result in retaliation or violence. * 1 2 3 4 5
Please describe the frequency with which this type of incident occurs. *- Select -OnceRarely (2-3 times)On a regular basisEveryday
Did this or other incidents make you feel like harming yourself or others? * Yes No
Would you like to speak with a counselor or an Administrator? * Yes No If you did not add your name at the beginning of the survey then you must add it here if you want a counselor to follow up with you.
What else would you like us to know about this incident? (optional)