Central Middle School Bullying Report Form
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Bullying Report Form
Click "Done" when finished. An email will be sent immediately to CMS administration. Thank you for helping make Central Middle School a safer place for all students.
Name of person being bullied:
Date bullying occurred:
Name of bully:
Your Name (optional):
I am a:
Person being bullied
Type of Bullying (Select all that apply):
Physical - Hitting/kicking/otehr physical aggression
Verbal - Teasing/name-calling/put-downs/behavior that would hurt others' feelings or make them feel badly
Emotional/Exclusion- Starting rumors/telling others not to be friends with someone/actions that would cause someone to be without friends
Cyber - Using an electronic medium to engage in any previously mentioned 'bullying'
Description of events: (Please be specific-Location/Date/Time)
Did you witness the bullying?
List other students/staff who witnessed the bullying...