Bullying Report Form
Bullying Definition: Bullying is unwanted, aggressive behavior that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time.

The purpose of this form is to report an incident of bullying. D123 Board Policy regarding bullying can be found at: http://goo.gl/2YGv7v

Your First Name
(Optional)
Your answer
Your Last Name
(Optional)
Your answer
You are reporting this as a... *
If you are a student, please let us know your grade level.
School
Date the incident occured *
MM
/
DD
/
YYYY
Time the incident occured
Time
:
Location of Incident *
Required
Bullying Behavior
Please check all the choices below that relate to the incident
Cyberbullying
Physical
Social
Emotional
Name(s) of those involved
Please list the FIRST and LAST names. if unknown type "unknown." Please separate names with a comma and do not press ENTER or RETURN
Your answer
Name of the person/people being bullied *
Please list FIRST and LAST names. If unknown, type "unknown." Please separate names with a comma and do not press ENTER or RETURN.
Your answer
Detailed Description of What Happened *
Please describe in detail what happened. Please include first/last names, where and when it occurred. You can include steps you/others took to stop this behavior and other details you feel we need to know to help. Please do not use quotation marks and make sure to not press ENTER or RETURN...keep all your text together as one paragraph.
Your answer
If you would like to talk with someone...
If you would like to talk to someone at school about this issue, please check off who you'd like to speak with below.
If you would like to speak with someone, please list your contact information below including your name, phone number and email address.
Your answer
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