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Bully Report Form

We would like to ensure that Oberlin schools are safe for all students. Please provide us with as much information as you can about the bullying situation.  Thank you!

Your Name:

Your E-mail:

Your phone number:

Write the name(s) of the person(s) who is bullying someone:

Write the name(s) of the victim(s):

Were there witnesses?  

        If so, write the name(s) of the witness(es): 

Home many times has this occurred:  

Write the date and time of the incident:

Describe the bullying incident:

What action do you think needs to be taken?  Choose all that apply: 

    Nothing.  Just document the incident in case of future problems.

    I would like you to talk with the student.

    I would like you to do what you can to stop the situation.

    I would like you let teachers know to watch out for this.

Whom should this form be sent to?  Choose all that apply:

    Mr. Jimenez - DCHS Principal

    Mrs. Breth - DCHS Counselor