Bullying Incident Report
Bullying means a single significant act or a pattern of acts by one or more students directed at another student that exploits an imbalance of power and involves engaging in written or verbal expression, expression through electronic means, or physical conduct that occurs within or outside of school property that:
1. Has the effect or will have the effect of physically harming a student, damaging a student’s property, or placing a student in reasonable fear of harm to the student’s property;
2. Is sufficiently severe, persistent, and pervasive enough that the action or threat creates an intimidating, threatening, or abusive educational environment for a student;
3. Substantially disrupts the educational process or the orderly operation of a classroom or school based activities.
4. Includes cyberbullying.
This form may remain anonymous. Students may also use this form to report a bullying incident. An administrator will respond to reports submitted within 3 business days. Please send any additional evidence (i.e. screenshots, photos, etc.) to
Date of incident
Time of incident
Location of incident
Description of incident
Were you a witness to the hurtful behavior?
Your email address
Your phone number
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This form was created inside of Mount Sacred Heart Catholic School.