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Bullying Incident Report for Temecula Valley Charter School
For students or parents. This report will be read by the administrator and/or designee. All reports will be investigated.
Date of incident
Your answer
Time of incident: be as specific as you can be
Your answer
Did this happen at school?
If this did not happen at school, where did the incident occur?
Your answer
If this incident did occur at school- what was the location?
Describe the incident:
Your answer
Name the victim(s).
Your answer
Name the person(s) who were bullying.
Your answer
Name the person(s) who were bystanders or witnesses.
Your answer
Describe any physical injuries:
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Please name all adults the incident was reported to:
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Optional: your name
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