Buna

ELEMENTARY ELEMENTARY

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.

Please Fill Out The Bullying Incident Report Form Below

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

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

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

Email a copy to

optional

mack

Rhonda Mack

2019.2020

District	Campus	Directory
	CAMPUS

Bullying Incident Report Form

BES Teacher of the Year