Bullying Report Form
The person reporting the bullying incident has the option of including his or her name on this form OR submitting the form anonymously. Anonymous reports are more difficult to investigate.
Please answer all sections that apply. This form will go to the principal/supervisor at the building where the bullying event occurred.
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Are you a student, parent, friend, teacher, school staff member or witness to the bullying? *
Your Name (Optional)
School where the incident occurred: *
Date & Time of the Incident: *
Location of the incident (hallway, playground, etc): *
Person or persons doing the bullying: *
Name/Grade of the person who was the victim (if not you): *
If you were not the victim, how did you learn about the alleged bullying incident?
Describe what took place, such as the type of bullying (verbal, written, physical, or online) and any other important information: *
Name/names of anyone else who witnessed the incident:
This report is filed based on my honest belief that the above mentioned person has bullied or was violent to another person or to me. I certify that this information is true and complete to the best of my knowledge. If you are agree to this statement, please submit this report now.
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