Bullying
Bullying Incident Report Form for Use by Parents, Students, and Community Members.
Reporter (Person Filing the Report)
Date Filed
MM
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YYYY
First and Last Name:
Your answer
Address:
Your answer
Phone Number:
Your answer
Email Address:
Your answer
Relationship to the student being bullied (parent/guardian,fellow student, community member, etc:
Your answer
I prefer to remain anonymous. (The district will investigate all allegations of bullying, but it is more difficult to follow up on anonymous reports.)
Bullying frequently involves repeated behavior. If you have witnessed or have knowledge of more that one incident, please provide information on all incidents. Please feel free to use multiple forms or attach additional pages if necessary to report all related incidents.
Did you witness this incident?
If no, provide specific information as to how you found out about this incident:
Your answer
Details of Incident
What is the approximate date that this incident occurred?
MM
/
DD
/
YYYY
What is the approximate time that this incident occurred?
Time
:
Where did the incident take place? (Be as specific as possible . For example, instead of "the middle school. " specify "the sixth-grade men's bathroom at the middle school."
Your answer
Please provide the name of the student or students who were the target of the bullying and include Grade Level and the School of Attendance:
Your answer
Please provide the name of the student or students who were engaging in the bullying behavior and include Grade Level and School of Attendance.:
Your answer
List the names of others who witnessed or may have witnessed the incident:
Your answer
Please describe the incident. (Include as much detail as possible. Do not "clean up" anything that was said or done. If inappropriate language or gestures were used, include the exact language and describe the exact gesture used.)
Your answer
Is there any other information you believe is relevant for the district to know when investigating this incident?
Your answer
This report should be accompanied by any applicable evidence that bullying occurred, such as copies of notes, emails or photos. If the bullying includes sexting, nudity, or inappropriate images of a minor, please d NOT copy, download or further distribute the images! Instead, show the evidence to the principal immediately so that appropriate action can be taken.
Once submitted, this form will be forwarded to the appropriate staff member for further action.
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