Middle School Bullying Incident Form

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Name of student/victim: *

Name of bully: *

Date and time of day that the bullying happened: *

YYYY

Time

Where did the incident happen? *

Check all that apply.

Classroom

Hallway

Restroom

Locker room

Lunch room

Bus

On the way to/from school

Internet

Cell phone

At school-sponsored activity

Required

Which statement best describes what happened? *

Check all that apply.

Teasing, name calling, making critical remarks or threatening, in person or by other means

Excluding or rejecting student from activities

Told lies or harmful rumors about the student

Making racial comments or jokes about the student

Took or damaged others possessions

Made rude and/or threatening gestures (imitating)

Getting another person to hit or harm the student

Required

What other comments or statements do you have about the incident?

Submit

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