BULLYING INCIDENT REPORTING FORM
Bullying is REPEATED use by one or more students of a written, verbal or electronic expression or a physical act or gesture or any combination thereof, directed at the victim that causes or places the victim in reasonable fear of harm to himself or of damage to his property, creates a hostile environment at school for the victim, infringes on the rights of the victim at school, or disrupts the education process.
Cyber-bullying is bullying through the use of technology or any electronic communication, which shall include but is not limited to electronic mail, internet communications, instant messaging, posting on social networking sites, or facsimile communications.
Date of report: *
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Name of person reporting the incident.
(Leave blank if you wish to remain anonymous).
Name:
Your answer
If you are the person who suffered from the incident, then select Target. If you are reporting the incident, then select Reporter.
You are the: *
You are a(n): *
Your contact information/telephone number:
(Leave blank if you wish to remain anonymous).
Your answer
Which school or work site should receive this report?
School or work site: *
If the target is a student, please state which grade the student is in.
Grade:
Name of the person(s) who suffered the aggression.
Target(s): *
Your answer
Name of the person(s) who committed the aggression.
Aggressor(s): *
Your answer
Date of incident: *
MM
/
DD
/
YYYY
Time of incident: *
Time
:
Location of incident (be as specific as possible): *
Your answer
List people who saw the incident - Bystanders.
Bystander (1):
Your answer
What is the role/position of the Bystander?
Position (1):
Bystander (2):
Your answer
Position (2):
Bystander (3):
Your answer
Position (3):
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).
What happened? *
Your answer
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