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Bullying Incident Reporting Form - Avon District
Note:
Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.
* Indicates required question
Name of Reporter/Person filing the report:
This line may be left blank if anonymous report is being made.
Your answer
Check whether you are the:
*
Target of the behavior
Reporter (not the target) of the behavior
Check whether you are a:
*
Student
Staff Member
Parent/Guardian
Other:
Your telephone number:
This line may be left blank if anonymous report is being made.
Your answer
Your telephone number:
This line may be left blank if anonymous report is being made.
Your answer
If you are a student, your grade:
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Clear selection
Information about the incident:
Your answer
Name of target of behavior:
*
Your answer
Name of aggressor (person who engaged in the behavior):
*
Your answer
Date(s) of incident(s):
*
Your answer
Time(s) when incident(s) occurred:
Your answer
Your answer
Location of incident (please be specific):
*
Your answer
Describe the details of the incident (including names of people involved, what occurred, and what each person said, including specific words used).
*
Your answer
Witnesses
Please include the names of people who saw the incident or have information about it.
Your answer
Witne
s
s 1 Name
Your answer
Witness 2 Name
Your answer
Witness 3 Name
Your answer
Witness 4 Name
Your answer
Witness 5 Name
Your answer
Submit
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