Bullying Reporting Form


This form will be submitted to the building Principal and Assistant Principal, if applicable.
Name of Reporter/Person Filing the Report (Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.)You may choose to write anonymous if you choose.
First Name
Last Name
You may choose to write anonymous if you choose.
Your contact information/telephone number:
Not required if you wish to remain anonymous.
Measures taken to ensure safety of target and reporter:required
Are you the:required
Your role at Mount Greylock Regional School District:required
If "Other," please specify:
Grade Levelrequired
Which school?required
Name of target:required
Person who experienced the behavior (if known or unknown)
Name of the aggressor:required
Person who engaged in the behavior (if known or unknown)
Date(s) of Incident(s):required
Time when incident(s) occurred:required
Location of incident(s):required
Please be as specific as possible
List witnesses (people who saw the incident or have information about it). Please list each Witness by Name and identify as Student, Staff, or Other.required
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used). required
Email Address
If you wish to receive a copy of this form.