Student Bullying Incident Report Form
Bullying: Unwanted physical or verbal assault, repeated over time that usually involves an imbalance of power where someone is regarded as weaker or different.

1) If you are a student or youth, don’t forget to talk to your parents or guardians about the incident.
2) If you are being threatened, contact local police immediately, or have your parents call them for you.
3) Help your school help you. Complete details of the incident are required for your school to investigate.

Enter your full name *
Your answer
Your Phone Number *
Your answer
Your E-mail
Your answer
Your Grade
Your answer
Are You: *
If you are not the student, what is the name of the student allegedly bullied?
Your answer
What school do you attend?
Where did the incident happen? *
Your answer
Tell us what happened:
Your answer
What is the person's name that did the alleged bully?
Your answer
Who else witnessed this incident?
Your answer
Have you already notified any school staff? Who?
Your answer
Date of incident
MM
/
DD
/
YYYY
Time of incident
Time
:
Help us understand clearly what form the bullying took in this incident, check all that apply:
I agree that all the information on this form is accurate and true to the best of my personal knowledge. *
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