Bullying Incident Report

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In order to help to create a bully free environment, we have created a form for students, parents, and staff to use that will allow for reporting of bullying in our school. Bullying and harassment reports will be fully investigated and taken very seriously. If further information is needed to investigate the report, we will need your contact information. Once a report is made, the reporter may not be made aware of action steps due to student privacy.

Email *

Person making this report is a ... *

Student

Parent

Staff Member

Other:

Name of person making report (In case further information is needed to investigate. You will not be identified as a reporter. Only Mr. Erickson and Mrs. Cregan have access to this document) *

Name of person being bullied or harassed and their grade level. *

Were you a witness to the bullying/harassment?

Yes

Other:

Clear selection

List any one else that was a witness to the incident.

What is the name and grade of the person(s) doing the bullying. *

What type of behavior was this? *

Verbal (name calling, threats to harm, etc.)

Physical (hitting, kicking, biting, etc.)

Relational (spreading rumors, social media, emails, text messages, gestures, exclusion etc.)

Other

Other:

Where did this incident take place? Check all that apply. *

Hallway

Bathroom

Classroom

Gym

Cafeteria

Library

Bus

Playground

On the way to or from school

Online

Other:

Required

Describe the incident as detailed as you can. *

Have you reported this incident to anyone else?

Yes, an adult at school.

Yes, my parents.

Yes, my friends.

No, I haven't told anyone.

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