Ben Franklin - Anti-Bullying Report

 
Page 1 of 1
 
  
Respond to the questions that you can accurately and comfortably answer. You may choose to include your name at the bottom of the form or may submit it anonymously. Please note that the district’s ability to investigate an anonymous complaint may be limited, and the district prohibits retaliation against anyone who files a bullying report.

 
 

"Bullying" means any physical, written or verbal behavior (including the use of electronic technologies) occurring or received on school property or pattern of such behavior that causes distress to one or more students or substantially disrupts the educational environment. This also may interfere with another student or students' educational benefits, opportunities, or performance. The behavior may be so severe and pervasive that it places the student in actual or reasonable fear of harm and/or in actual or reasonable fear of damage to property. View Anti-Bullying Policy.
   
 
 
   
 
(select approximate time)
 
   
 
  Select Date
mm/dd/yyyy
   
 
 
   
 
(select location)
 
   
 
 
   
 
(if you don't know the bully's name(s) describe him/her)
 
   
 
(if you don't know the victim's name(s), describe him/her)
 
   
 
(if yes, please list)
 
   
 
(if yes, please explain)
 
   
 
(if yes, please explain)
 
   
 
 
   
 
(example: parent, babysitter, brother/sister, teacher, family member, etc)
 
   
 
(if yes, please indicate number of times and details)
 
   
 
 
   
 
 
   
 
 
   
 		  
 
 Submit