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
Did you report the bullying incident to a teacher? If so whom did you report the incident to?
Name of victim(s)
Name of student(s) bullying
Name(s) of witnesses/bystanders
How many times has the bullying occured?
More than 3 times
Where did it happen?
Hitting or Kicking
Shoving or Pushing
Gossip or Rumors being spread
What did the bully/bullies say or do?
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