Bullying Incident Report
The Benjamin Franklin Middle School and The Gereau Center are compelled to keeping our students safe.Before you report: What is bullying? “any aggressive and unwanted behavior that is intended to harm, intimidate, or humiliate the victim; involves a real or perceived power imbalance between the aggressor or aggressors and victim; and is repeated over time or causes severe emotional trauma."
Email address *
1. Your role- *
2. Where did the incident occur?
Your answer
3. When did the incident happen? *
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DD
/
YYYY
4. What time did the incident happen? *
5. Has the incident happened before? *
6. Describe the incident. *
Your answer
7. What grade is the victim in? *
8. Victim's name *
Your answer
9. Bully's name *
Your answer
10. What grade is the bully in?
11. Name(s) of (witness/bystanders) someone who saw what happened. *
Your answer
12. Bullying behavior (check all that apply) *
Required
13. Was there CyberBullying Behavior on the Internet (check all that apply) *
Required
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