Listening Lockhttps://www.spps.org//cms/module/selectsurvey/SurveyOptionser
Report Bullying or a Dangerous Situation.
FOR IMMEDIATE ACTION PLEASE CONTACT AN ADMINISTRATOR
1.
Person Reporting the Incident
Enter your first and last name
2.
Reporting Person's Student ID Number
3.
Reporting Person's Grade Level
--None--
6
7
8
9
10
11
12
4.
Where did it happen?
--None--
1st Floor Men's Restroom
2nd Floor Men's Restroom
3rd Floor Men's Restroom
1st Floor Women's Restroom
2nd Floor Women's Restroom
3rd Floor Women's Restroom
1st Floor Hallway
2nd Floor Hallway
3rd Floor Hallway
Boy's Locker Room
Girl's Locker Room
Staircase
School Bus/Bus Stop
Library
Gym
Cafeteria
Classroom
Other
5.
Additional Information on Location
Please describe more specific details about the location. Examples - bus stop location, bus route letter, classroom number, and section/area of the school building.
6.
When did it happen?
7.
Identify the behaviors received/observed
Please check all that apply.
Physical Violence (hitting, kicking, pushing, spitting, throwing objects)
Verbal Threats/Harassment
Spreading Rumors
Name Calling/Teasing
Cyber Bullying/Online Posting
Public Humiliation/Embarrassment
Sexual Harassment
Inappropriate Sexual Contact/Sexual Assault
Sexual Orientation Related
Disability Related
Race/Ethnicity/Cultural Background Related
Gender/Gender Roles
Theft
Possession of a Weapon
Possession of Drug/Drug Use
Possession of Tobacco/Tobacco Use
Possession of Alcohol/Public Intoxication
Gambling
Destruction of School Property
Safety Hazard
Other, please specify
8.
Please describe in detail what happened
9.
How often did this incident happen?
How often did this incident happen?
Once
Twice
Three or more times
Everyday
10.
Who was involved?
Please use first and last name if possible. If you don't know name(s), please describe the person(s) using identifiers such as gender, race, height, clothing/accessories and specific key features.
11.
Anyone physically injured? If so, please describe the injuries
12.
List witnesses or anyone with more information on the incident
13.
Need a School Counselor/Social Worker to follow up?
Need a School Counselor/Social Worker to follow up?
Yes, I want a School Counselor/Social Worker to follow up with me.