Bullying Report Form
Bullying means systematically and chronically inflicting physical hurt or psychological distress on one or more students.

Bullying is not mutual conflict, one random act of violence or harassment, a childhood “rite of passage” that all students must endure.

If you feel you have been a victim of bullying or know of someone that has been a victim of bullying, please report any information here.

This form is confidential and will only be reported to campus administration.

Name of Person Reporting Incident (Optional):
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Telephone Number of Person Reporting Incident:
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Email Address of Person Reporting Incident:
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I am a ....
Required
Student Victim's Name:
Your answer
Student Victim's Grade:
Name(s) of Alleged Offender(s):
Your answer
Date Incident Happened:
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DD
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Where Did the Incident Happen? (Choose all that apply)
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Has this Happened Before?
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Type of Bullying (Choose all that apply).
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Describe What Happened (Include as many details as possible).
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Where there any Witnesses
Name(s):
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Any Other Information We Need to Know?
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