You don't have to tell us your name, we just want to make sure you stay safe!
Date it happened?
Time it happened?
How many timeshas this happened?
This is the first timeOne other timeOnce a weekOnce a monthEvery dayThis is the first time
Have you reportedthis to an adult?
Yes
No
Did you report this to a teacher, counselor or other school staff member before filling out this form?
Which school or location did this occur? Jemez Valley Elementary SchoolJemez Valley Middle SchoolJemez Valley High SchoolBusOther
Where did it happen? In classIn front of the schoolIn the bathroomIn the cafeteriaIn the gymIn the hallwayIn the locker roomIn the parking lotOn the busOn the fieldOver the phone or voicemailIn an emailIn a textOn Social MediaOther
Who is bullying or harming you? (Include first & last name and grade if known)
Who is the person being bullied or harmed? (Include first & last name and grade if known)
Describe what happened with as many details as you can, include the names of others who saw this happen.
Who are you? StudentRather not sayTeacherStaff MemberParentVolunteerOther
What is your name (Optional, you don't have to tell us your name).
If you'd like us to contact you by email, please provide your email address
If you would like us to contact you by phone, please enter it below.
Once you submit this report we will investigate this further and contact you if you have provided an email or phone number.
Thank you for taking time to share this important information as this helps us establish an anti-bullying environment for everyone.