Bullying and School Violence Report Form Name* First Last Relationship*StudentParentStaffBuilding*Sycamore High SchoolSycamore Middle SchoolNorth Elementary SchoolNorth Grove Elementary SchoolSouth Prairie Elementary SchoolSoutheast Elementary SchoolWest Elementary SchoolDo you prefer to remain anonymous?*YesNoAre you the target of the bullying or school violence that you are reporting?*YesNoWho is being bullied?*Who is doing the bullying?*Are there any witnesses?*Type of Bullying*Electronic Device (internet, social media, text, email, cyberbullying, etc.)Written Communication (handwritten notes, other written documents, email, etc.)Physical Act or conduct (pushing, hitting, destruction of property, stalking, etc)Verbal Act of Conduct (rumors, lies, name-calling, using derogatory slurs, etc.)Social (purposeful exclusion, causing psychological harm, etc.)Physical BullyingDid the physical bullying result in an injury?*YesNoWas it reported to the nurse?*YesNoWas it reported to the police?*YesNoIncidentDate of Incident*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Approxiamete Time of Incident* : HH MM AM PM Location of Incident* Classroom Hallway Cafeteria Restroom Gym Locker Room Extracurricular Activity Bus Bus Stop School or related activity or event Does not Apply Please tell us about the incident in your own words. Use as much as possible - who witnessed it, what was said, what types of interactions occurred (physical, written, social, electronic, etc.)*Please attach any information you would like included in this report. Drop files here or Accepted file types: jpg, png, pdf.