St. Ignatius Bullying Report Form

Bullying, harassment, or intimidation means intentional unwanted, aggressive behavior with an imbalance of power, it may include verbal, physical, written or electronic conduct/communication that is repeated.

Date Date / MM / DD YYYY
Person reporting Person reporting First Last
Email
Date(s) of incidents(s):
Choose all that apply

Choose all that apply Verbal Physical Emotional Social Media Other
Persons involved:
Where did this occur?
Has this happened before?
Dates?
Is there additional information available, such as, letters, screenshots, photos or other? If yes, please provide to principal or school counselor.

Is there additional information available, such as, letters, screenshots, photos or other? If yes, please provide to principal or school counselor. Yes, I have more information to turn in. No, just this form.
Explain this incident?
Describe what you have done to resolve or what you think would resolve this problem?
Parent signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Student signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.