Bullying Incident Reporting Form
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.
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: *
Check whether you are a: *
Your telephone number:
This line may be left blank if anonymous report is being made.
Your answer
Your email address:
This line may be left blank if anonymous report is being made.
Your answer
If you are a student, your grade:
Information about the incident
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
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.
Witness 1 Name
Your answer
Witness 2 Name
Your answer
Witness 3 Name
Your answer
Witness 4 Name
Your answer
Witness 5 Name
Your answer
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