McClure Junior High Anonymous Reporting Form If you have any information you would like report regarding bullying committed against you or a fellow student and would like to report this information anonymously, please fill out this form to the best of your knowledge. Bullying consists of but is not limited to personal threats, acts of violence, verbal abuse, written or electronic (text messages or e-mails) abuse and teasing, which is repeated over time. If you fear that you or another student is in IMMEDIATE danger, contact Mrs. Broadnax or Mr. Sturm right away.

Name (optional)

Grade

Please select your grade6th Grade7th Grade8th Grade

Date and Time of the incident

MM / DD / YYYY HH : MM AMPM AM/PM

Where did the incident occur?

Please describe, in as much detail as possible, what happened.

Do you know any witnesses? If so, please provide as much detail as possible about these people.

List evidence of bullying if any (i.e. letters, photos, etc.)

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