Report Bullying

* Email Address

* Contact Name

What kind of bullying? (Check all that apply.)

How many times?
Select... 1 time Once a Day More than Once a Day Once a Week More than Once a Week Once a Month More than Once a Month Once a Year More than Once a Year

Age of Child
Select... Under 5 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Over 18

School Grade
Select... Kindergarten 1 2 3 4 5 6 7 8 9 10 11 12 Other

Reported to School?
Select... No Yes

Did the School Resolve Bullying Incident(s)?
Select... No Yes

School Name

School District

County

State
Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other (Outside US)

* = required field