Anonymous Bullying Report Form
Name of Reporter/Person Filing the Report *
(Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.)
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Check whether you are the: *
Check whether you are a: *
Your contact information/telephone number:
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If student, state your school:
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If student, state your grade:
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If staff member, state your school or work site:
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Information about the Incident:
Name of Target: *
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Name of Aggressor: *
Person who engaged in the behavior
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Date(s) of Incident(s): *
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Time when Incident(s) Occurred: *
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Location of Incident(s): *
Be as specific as possible:
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Witnesses:
Witness name 1:
List people who saw the incident or have information about it:
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If other, please specify:
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Witness name 2:
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If other, please specify:
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Witness name 3:
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If other, please specify:
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Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used) *
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