Bullying Report Form
Bullying occurs when a student or group of students engages in written or verbal expression, expression through electronic methods, or physical conduct against another student. For bullying to be addressed by the school, it must occur on school property, at a school-sponsored or school-related activity, or in a district-operated vehicle, and the behavior:
-- Results in harm to the student or the student's property,
-- Places a student in reasonable fear of physical harm or of damage to the student's property, or
-- Is so severe, persistent, and pervasive that it creates an intimidating, threatening, or abusive educational environment.
Date of the Incident
Time of the Incident
Location of the Incident
What type of bullying occurred?
Non-verbal (exclusion, eye-rolling, etc.)
Victim's Name and Grade (If you do not know the grade level, please provide the campus.)
Name of the Person(s) Doing the Bullying (If you do not know their name, then provide a detailed description of them.)
Description of the Event (This can be what happened to you if you were the one being bullied or what you witnessed from someone else being bullied. Try to provide as much detail as possible.)
Are there any witnesses of the bullying? If so, please provide their names.
How did you become aware of the incident?
I am the victim.
I am a witness.
It was reported to me by the victim.
I would rather not say.
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