Bullying Incident Report

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In order to help to create a bully free environment, we have created a form for students, parents, and staff to use that will allow for reporting of bullying in our school. Please keep in mind that reporting bullying and harrassment will be taken seriously. If further information is needed to investigate the report, you will be contacted. There may be times when contacting the reporter is not appropriate due to privacy. Please be assured that all reports will be taken seriously.

Email *

Status of person making this report: *

Student

Parent

Staff

Other

Name of person making the report *

Phone number or email address in case we need to contact you *

Name of Victim(s) and Grade(s) *

Did you witness the bullying occur? *

Yes

Who else was a witness *

Name and Grade of person doing the Bullying *

Type of Incident: *

Physical (e.g. assault, hitting or punching, kicking, theft)

Verbal (e.g. threatening or intimidating language, teasing or name-calling, racist remarks)

Indirect (e.g. spreading rumors, intimidation through gestures, social exclusion and sending insulting messages or pictures by mobile phone or using the internet)

Time of Incident: *

During the school day

Outside of the school day, but during school-related activities

Outside of the school day or during non-school-related activities

Location of the Incident: *

Hallway

Playground

Gymnasium

Cafeteria

Library

Bathroom

Bus

Classroom

On the way to/from school

On line

Texting

Other:

Required

Describe the bullying incident: *

Submit

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