BULLYING INCIDENT REPORT FORM
Anonymous and Confidential Reporting System utilized only by the Administration of Belvidere High School
Date of Incident
MM
/
DD
/
YYYY
Time
:
Location of Incident
Check all that apply
Required
Name of Victim(s)
Write all Names Here
Your answer
Name of Student(s) Bullying:
Your answer
Name(s) of Witnesses/bystanders:
Your answer
Did the bullying result in physical harm?
If Yes, who was it reported to?
Check all that apply
Bullying Behaviors:
Circle all that apply
Required
Reported to school by
Check all that apply
Describe the incident:
Be as DETAILED as possible. What was said? What did you see?
Your answer
Physical Evidence
Your Name and Contact Information
Optional- you may give it if you want to turn in evidence or meet in person with the administration
Your answer
Submit
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