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Elmer H. Franzen
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FRANZEN BULLY REPORT
FRANZEN BULLY 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
Target of Bullying
Witness
Staff Member
Parent/Guardian
Community Member
Other:
Today's Date
*
Answer Required
Name of Alleged Bully
*
Answer Required
What date did the incident occur?
*
Answer Required
What time of day did the incident occur?
Answer Required
Where did the incident occur?
*
Answer Required
Hallway
Classroom
Bathroom
Lunch
Recess
Gym
On the Bus
Bus Stop on the way to/from school
Library
Other:
Type of Bullying (may be more than one)
Answer Required
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
Other:
Has the alleged bully done this to the same victim on other occasions?
*
Answer Required
Yes
No
I don't know
Please describe the incident that occurred. Be as specific and accurate as possible.
*
Answer Required
Your name / grade (optional)
Answer Required
Confirmation Email
Confirmation Email
Email Required
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