Bully Incident Report
This report will be sent directly to the Jim Hill Office. Please complete by only responding to the questions that you feel comfortable answering and are able to accurately answer. Thank you for standing up for yourself or someone else.
First and Last Name of the Reporter will be Confidential *
Your answer
Date *
Your answer
Your answer
Victim *
Your answer
Bully *
If you do not know the bully's name describe him/her.
Your answer
Desribe what happened. *
Your answer
When did the incident take place?
Where did the incident take place?
Did anyone else witness the bullying?
If yes list in other category.
Were you or others physically hurt?
If yes explain in Other category.
Was there damage to anyone's personal property?
Have you or the victim missed any school or made changes to your daily routine as a result of the incident(s)?
Have you told anyone about the bullying?
Have you previously filed a bully report(this information is used to determine if retaliation is occurring)? *
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