BULLYING INCIDENT REPORT
* Required
Date of Incident:
*
Your answer
Time of Incident:
*
Time
:
AM
PM
Location of Incident
*
Hallway
Restroom
Classroom
Gym
Cafeteria
Playground
Locker Room
Bus Stop
On Bus
To/From School
After School Program
School Sponsored Event
Text/Phone/Internet/Social Media
Other:
Required
Name of victim(s):
*
Your answer
Name of student(s) bullying:
*
Your answer
Name(s) of witnesses/bystanders:
Your answer
Type of Bullying:
*
Verbal
Physical
Relational
Required
Resulted in injury?
*
Yes
No
Reported to School Nurse?
*
Yes
No
Reported to Police?
*
Yes
No
Bullying Behaviors (Check all that apply)
*
Shoved/Pushed
Hit, Kicked, Punched
Threatened
Stole/Damaged Possessions
Told Lies or False Rumors
Inappropriate touching
Demeaning Comments
Writing/Graffiti
Taunting/ridiculing
Intimidation/Extortion
Text messages
Website
Other:
Required
Reported to school by (Check all that apply)
Teacher
Student
Bystander
Victim/Target
Parent
Bus Drive
Anonymous
Other:
Describe the incident:
Your answer
Option 1
Clear selection
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