Harassment Intimidation Bullying Incident Report Form
If this is an emergency that needs immediate attention please call 911 or contact your health care provider immediately as this site is only monitored during school hours.
Please be advised, if a report is made anonymously it will limit our investigation process and we will be unable to follow up with the person making the report.
Students found responsible for deliberately making false reports may be subject to a full range of disciplinary consequences.
Name of person completing the form: (Contact information if possible)
Name of person(s) targeted:
Name of the person or people identified as the alleged aggressor(s):
Select the school building of the person being targeted:
What type of bullying are you reporting?
Incident Date (When did this happen?)
Incident Time (When did this happen? If possible.)
Incident Place: Describe where the incident(s) have taken place.
Incident Duration: (How long has this been going on?)
Incident Description: (Share details about what happened.)
Were there any witnesses?
What strategies have you used to try and deal with the situation?
Feel free to add additional information that may help the administrator in completing the investigation into this incident.
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