Bullying Incident Report
Name of person completing this report (optional):
Your answer
Role of person reporting (choose the one that applies):
Name of person being bullied:
Your answer
Grade level of person being bullied (if known):
Your answer
School where this incident took place:
Name of person bullying:
Your answer
Grade level of person bullying (if known):
Your answer
Describe the ongoing incident and what has happened.
Please provide as much details as possible.
Your answer
Where has this incident(s) occurred?
Please list witnesses to the events:
Your answer
How long has this been going on?
Your answer
How have you dealt with this situation up until this point?
Your answer
Who have you spoken to about this?
Your answer
Who do you want to be aware of the problem?
Your answer
What do you want to happen next? (At least 1 choice required)
Required
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