Anonymous Incident Report Form
This is a district-wide form used at Elmwood Community Schools to report (anonymously or non-anonymously) any kind of bullying, cyber-bullying, or harassment.
Last Name of Person Reporting Incident (Optional)
First Name of Person Reporting Incident (Optional)
Name of Victim(s)
Name of Student(s) Bullying
Name of Witnesses to Incident (If Any)
Date of Incident
Time of Incident
Location of Incident (Select All That Apply)
To/From School (Walking or Transport Other Than Bus)
After School Program
School Sponsored Event (Athletics, Activities, Away Games, etc.)
Digital (Text, Phone, Web, Social Media)
Type of Bullying (Select All That Apply)
Bullying Behaviors Observed (Select All That Apply)
Physical Violence of Any Kind: Shoved/Pushed, Hit, Kicked, etc.
Verbal Threats, Taunts, and/or Ridiculing
Stolen/Damaged Property or Possessions
Slander (Lites, False Rumors, Incitement, etc.)
Staring, Leering, and/or Actions Intended to Intimidate/Make Uncomfortable
Verbal Comments and/or Actions Intended to Intimidate/Make Uncomfortable
Sexual Harassment of Any Kind: Verbal, Physical, Inappropriate Touching/Groping, etc.
Harassment Based On Race, Sexuality, Religion, or Disability
Cyberbullying: Text, Phone, Web, Social Media, etc.
Did the incident result in any injuries?
If yes to the question above, was the incident reported to the school nurse and building principal?
Incident Was Reported to the Following School Personnel (Check All That Apply)
Other Staff Member
This Form (Anonymously)
This Form (Non-Anonymously--Name Included At Top)
Was the incident reported to the police?
Describe the Incident (Please use as many details as possible):
Is there physical evidence related to the incident?
If you marked yes above, please select any kinds of evidence that apply below:
Social Media Page/Account(s)
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This form was created inside of Elmwood Community Schools.