Bullying Incident Report

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Please use this form to report bullying incidents of or by DISD students/staff. You can report for yourself or for someone else. Please include as much information as possible, so that the district can fully investigate your report. You are not required to submit your name, but you may do so if desired.

Please enter the name of the person who was bullying another person. *

If you know it, please enter the school of the person who was bullying another person.

If you know it, please enter the grade level of the person who was bullying another person.

Please enter the name of person who was being bullied. *

If you know it, please enter the school of the person who was being bullied.

If you know it, please enter the grade level of the person who was being bullied.

Where did this bullying incident take place? *

At school - in the classroom/gym/computer lab

At school - in the bathroom/hallway/cafeteria

At school - on the playground/outside

Via text or email

Via social media or online (blog/Snapchat/Facebook/Instagram/Twitter. etc.)

On the bus

Other:

Please explain the incident. What happened? Include as many details as possible. *

Please enter the date of the incident. *

YYYY

Please enter the approximate time of the incident. *

Time

Did you report this to anyone else? *

Yes

If your answer was YES, to whom did you report the incident?

Please enter a phone number so that you may be contacted if additional information is needed. *

OPTIONAL - Please enter your email address.

OPTIONAL - Please enter your name.

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