Bullying Incident Form
Please use this form to make an report to the school administration if you were involved or observed a possible bullying incident.
Name of the Person/Person filling the Report
Grade
Check whether you are the person
Check whether you are a
Date of Report
MM
/
DD
/
YYYY
Your contact information/Telephone number
Parents Name and Contact Information
Information about the Incident
Name of the Person being bullied
Name of Aggressor(Person who engaged in behavior)
Date(s) of incident(s)
Time when incident(s) Occurred
Location of Incident(s)(Be specific as possible)
Witnesses
Names(List of people who saw the incident or have information about it)
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used). Please use additional space on back if necessary.
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