Pacers-Bullying Incident Report Form
What is bullying? Bullying is repeated after you have told them to stop; is planned and done on purpose; the target of the bully is upset; the bully is trying to gain control over the target; the bully blames the target; the target wants to stop the bully's behavior-the bully does not; CANNOT be resolved through mediation.
Write your name if you like
Your answer
Teacher/Grade *
Your answer
Did you report the bullying incident to a teacher? If so whom did you report the incident to?
Your answer
Name of victim(s) *
Your answer
Name of student(s) bullying *
Your answer
Name(s) of witnesses/bystanders *
Your answer
How many times has the bullying occured? *
Where did it happen? *
What happened?
What did the bully/bullies say or do?
Your answer
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