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Peacock Bullying Report
Peacock Bullying Report
Please complete the form below. Required fields marked with an asterisk *
Please report on incidents that you have heard or witnessed.
I am a:
*
Answer required for "I am a:"
Target of bullying
Witness
Staff Member
Parent/Guardian
Community Member
Other:
Today's Date
*
Answer required for "Today's Date"
Name of alleged bully
*
Answer required for "Name of alleged bully"
What date did the incident occur?
*
Answer required for "What date did the incident occur?"
What time of day did the incident occur?
Answer required for "What time of day did the incident occur?"
Where did the incident occur?
*
Answer required for "Where did the incident occur?"
Hallway
Classroom
Bathroom
Lunch
Recess
Gym
On the bus
At the bus stop to/from school
Library
Other:
Type of bullying (may be more than one)
Answer required for "Type of bullying (may be more than one)"
Relational/Emotional Aggression
Starting rumors
Excluding an individual
Telling others not to be friends with someone
Physical Aggression
Hitting/Kicking
Verbal Aggression
Teasing
Name Calling
Put downs
Behavior that would hurt feelings
Cyberbullying - Texting
Cyberbullying - Social networks (Facebook, etc.)
Cyberbullying - Email
Cyberbullying - Other electronic means
Option
Other:
Has the alleged bully done this to the same victim on other occasions?
*
Answer required for "Has the alleged bully done this to the same victim on other occasions?"
yes
no
I don't know
Please describe the incident that occurred. Be as specific and accurate as possible.
*
Answer required for "Please describe the incident that occurred. Be as specific and accurate as possible. "
Your name/grade (optional)
Answer required for "Your name/grade (optional)"
Confirmation Email
Confirmation Email
Answer required for "Confirmation Email"
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