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Bullying Incident Report Form

Please complete this form to the best of your knowledge so we can assist you.
This information will be kept confidential with your campus administrator and/or superintendent.

Date of Incident:
Date of Report
Who was the person(s) engaged in bullying?
Grade of person(s) who engaged in bullying?
Who was being bullied?
Grade of person who was being bullied?
What type of bullying?
Physical
Emotional/Social
Damage to Property
Online
Where did the incident take place?
After School Program
Bus
Bus Stop
Cell Phone
Classroom
Hallway
Gym
Internet
Locker Room
Lunch Room
Parking Lot
Playground
Restroom
School Sponsored Event
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). Please use your full name.
May we contact you for more information on this incident?
Yes
No
Thank you for reporting this incident. We appreciate your concern. When you click "Submit Form" this will be sent to the campus administrator.
Please duplicate the letters and/or numbers you see below to
verify that you are a valid user of this form.
These are the letters you will duplicate in the box below.
Email a copy of my form submission to (optional).