Bullying Incident Report
Please fill out as much detail as possible. You can stay anonymous or you may provide your name.
Date of incident
MM
/
DD
/
YYYY
Time of incident
Roughly what time did the incident occur?
Time
:
Location
Check all that apply
Name of victim(s)
Your answer
Name of Student(s) bullying
Your answer
Names of wittnesses/bystanders:
Your answer
Type of Bullying
Any physical evidence? (notes, texts, calls..)
Your answer
Describe the incident
Include as much detail as possible
Your answer
If you'd like to give us your name, we will be in contact with you about this incident. Or you may wish to stay anonymous.
Your answer
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