Anonymous Bullying Report
What date did the bullying incident occur?
MM
/
DD
/
YYYY
Who is the target/victim of the bullying incident? Please give first and last name.
Your answer
Name of the alleged aggressor/offender(s) of the bullying incident? Please give first and last name(s).
Your answer
Where did the incident happen? Check all that apply.
Required
Put a check next to the statement(s) that best describe(s) what happened
What did the alleged aggressor/offender(s) say or do?
Your answer
Did physical injury result from this incident?
Please explain any physical injury as a result of this incident.
Your answer
Did the injury require medical attention
Please explain any medical attention required as a result of this incident.
Your answer
Was the target/victim absent from school as a result of this incident?
If the victim was absent from school as a result of this incident, how many days were they absent?
Your answer
Please indicate how you know about this incident
School(s) involved and to be notified
Check all that apply. If unsure, leave blank.
Is there anything else we should know about this incident? You may optionally give your name if you wish.
Your answer
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