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."
1. Your role-
2. Where did the incident occur?
3. When did the incident happen?
4. What time did the incident happen?
5. Has the incident happened before?
6. Describe the incident.
7. What grade is the victim in?
8. Victim's name
9. Bully's name
10. What grade is the bully in?
11. Name(s) of (witness/bystanders) someone who saw what happened.
12. Bullying behavior (check all that apply)
hit, kicked, punched
excluded (deny a person to be part of the group/event)
taunting/made fun of
telling lies or false rumors
intimidation/demands food or money, etc
comments about race, religion, gender, or physical ability
13. Was there CyberBullying Behavior on the Internet (check all that apply)
cyberbullying on social media (instagram, snapchat, facebook etc.)
video or photo
Send me a copy of my responses.
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