Richland-Bean Blossom Community School Corporation Bullying Form: Please complete all of the areas below that you can. Information that is (*) starred is required. Thank you.



Who Are You?


Person Reporting Bullying (First Name and Last Name)(*)

Please let us know your name.

What is Today's Date(*)

Please select today's date.

When did the bullying happen?(*)

Tell us when it happened.


Who Was Bullied?


Who do you think was bullied? (First Name and Last Name)(*)

Please let us know the bully's name.

Where does this person attend school?

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Who is this person's teacher?

Please write a subject for your message.

What grade?




Who Is The Bully (or Bullies)?


Who do you think was bullying?(*)

Please let us know the person's name.

What grade?

Please let us know your name.

Type of Bullying (check all that apply)(*)








Select one type.

Where did the bullying happen? (check all that apply)(*)









Tell us where the bullying happened.


Other Information


Is this the first time that this has happened?(*)

Please answer this question.

Have you filed a Student Bullying Report before?(*)

Please answer this question.

Who has been told about the bullying or saw what happened? (check all that apply)(*)








Please tell us this.

Any other information that you would like to share?



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Our mission is to work in cooperation with the community and families to provide students with an education that promotes responsible citizenship and encourages problem solving and creativity.