Beauregard Parish School Board

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DJHS Bullying Report

DeRidder Junior High School Bullying Report

Date of Incident:

Date of Report:

What is the name of the person being bullied/threatened?

Grade of person who was being bullied/threatened?

What is the name of the person(s) engaged in the bullying/making threats?

Grade of person(s) who engaged in the bullying/making threats?

What type of bullying or threat?

Reaquired field: Physical

Reaquired field: Emotional/Social

Reaquired field: Damage to Property

Reaquired field: Online

Reaquired field: Other

Other:

Other location details: (Please explain the specific location details such as which hallway, where on the Internet, what restroom, etc)

Describe what happened with as many details as possible.

Person reporting the incident:(OPTIONAL)

May we contact you for more information on this incident?

Reaquired field: Yes

Reaquired field: No

If you checked "YES" that we may contact you, please provide your name and phone number.

Thank you for reporting this incident. We appreciate your concern. When you click "Submit Form" this will be sent to the campus administrator.

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DeRidder Junior High Bullying Report