Staff Bullying Report Form
Instructions: Please complete both pages, responding to all the questions as accurately as possible. If you are unsure of the answer t any question, please indicate so. School policy allows for the District to take disciplinary action against school staff who have knowledge/reasonable suspicion of a violation of the bullying policy and fail to report it.
Describe what happened/ what is happening:
Your answer
When did it happen?
Date:
Your answer
Time:
Your answer
Where did it happen?
List specific school room or event if applicable.
Your answer
Who was committing the bullying (if you're unsure of the bully's name(s) describe him/her)?
Your answer
Who was victim of the bullying (if you're unsure of his/her name describe him/her)?
Your answer
How did you learn of the incident? (if written report please attach)
Did anyone else witness the bullying?
Please list names of witnesses and/or anyone that may have information about the incident
Your answer
Were students/others physically hurt?
Please describe any physical injuries if any occurred.
Your answer
Have you noticed a change in the victim's routine (e.g., attendance patterns changed, grades dropped, avoids certain locations in the school)?
Please describe any changes in the victim's routine.
Your answer
If the bullying occurred online is there evidence that it was/has caused:
If applicable, please explain this evidence.
Your answer
In your view, was the incident motivated by any of the following traits (actual or perceived)?
Was the incident an act of retaliation against an individual who filed a previous bullying report and/or participated in an in investigation?
Have you reported the incident to law enforcement?
Your name (optional):
Your answer
Your school (optional):
Your answer
List your contact information (phone and/or email) (optional):
Your answer
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