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Clarksburg Elementary School Bullying Incident Reporting Form
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* Indicates required question
Name of Reporter/Person(s) Filing the Report
(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.)
Your answer
Check whether you are the:
*
Target of the behavior
Reporter (not the target)
Check whether you are a:
*
Student
Parent
Administrator
Staff Member (specify role below)
Other:
Your contact information: email or telephone number (if applicable):
Your answer
If you're a student, state your grade
Choose
K
1st
2nd
3rd
4th
5th
6th
7th
8th
Name of Target (of behavior):
*
Your answer
Name of Aggressor (Person who engaged in the behavior):
*
Your answer
Date(s) of Incident(s):
*
MM
/
DD
/
YYYY
Time when Incident(s) Occurred:
*
Time
:
AM
PM
Locations of Incident(s) (Be specific as possible):
*
Your answer
Witnesses (List people who saw the incident or have information about it:
Choose
Name:
Name:
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).
*
Your answer
eSignature of person filing this report:
Your answer
Date:
*
MM
/
DD
/
YYYY
Submit
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