Portageville Middle School Bullying Report Form

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This is a short form that will gather the information you provide and share it with the appropriate administration officials. Please complete this form as detailed as you can, as it will help us help you. All forms are submitted anonymously. Please use this form responsibly.

Email *

Name of the Victim? *

Name of the Bully? *

Where did this incident take place? (Example: Playground, Hallway, etc.) *

Approximate Date of Incident *

YYYY

What happened during this incident? *

How many times has this happened? *

One time

Two or more times

Have you reported this incident to anyone else? *

Yes

If you answered yes to the previous question, who did you report it to?

If you would like to leave your name, you can do so below. (Optional)

Submit

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