Bully Report

Bullying Incident Reporting Form

Name of Person Filing the Report:

Today’s Date

(Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.)

Select whether you are the:

Select whether you are a:

Information about the incident:

Name of Target (of behavior):

Name of Agressor (Person who engaged in the behavior):

Date(s) of Incidents(s):

Time When Incident(s) Occurred:

Location of Incident(s) (Be as specific as possible):

Witnesses (List people who saw the incident or have information about it):

Name:

Student Staff Parent Patron

Name:

Student Staff Parent Patron

Name:

Student Staff Parent Patron

Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).