Bullying Incident Reporting Form

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Reporting bullying or harassing behavior is the first step toward making our schools a safe place for everyone (this includes cyberbullying). Please report bullying if you are experiencing it, or witness it in school, on the bus, at school events, or online. Students knowingly sending in a false report will be subject to disciplinary actions up to and including suspension because this makes it harder for your school to help the students that really need it.

Use the following form to report bullying, which includes incidents of cyberbullying. Complete it online and it will be submitted directly to administration. Reports are held in the strictest of confidence.

Whether you are a witness or target in this case, we want to thank you for helping us maintain a positive and safe school environment for all of our students. (All names provided are kept confidential.)

* Required

Name reporting alleged bullying (optional)

Phone Number (optional)

Email (optional)

Relation to alleged victim of bullying *

Name of the alleged student victim *

Have you reported this incident to anyone in authority? (teacher, principal, or staff member at school) *

Yes

Name of alleged offender(s) if known *

Date of Alleged Incident *

YYYY

Time alleged incident occurred if known

Time

Check the statement(s) that best describe what happened. *

Physical: Hitting, kicking, pushing, shoving or other physical aggression

Verbal: Teasing, name-calling, put-downs, or other behavior that would hurt others'feelings or make them feel bad

Exclusion: starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends.Option 3

CyberBullying: Using a computer, cell phone, or other electronic device to engage in any previously mentioned bullying.

Other:

Required

Location of alleged incident *

Describe the incident(s), including what the alleged offender(s) said or did. *

Do you know why the bullying, harassment or intimidation occured? If yes, please give the specifics.

Name(s) of alleged witness(es) if known *

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