Campus Bullying Report Packsaddle Elementary
Incident Information
What campus is the bullying occurring?
Where did the incident occur? (Please give details of location.)
Your answer
What is the race of the victim?
What is the age of the victim?
Your answer
What is the gender of the victim?
Date of Incident:
MM
/
DD
/
YYYY
Type of Incident?
Who was bullying, harassing, intimidating or causing harm? (Include first name, last name and grade if known.)
Your answer
Who was the person being harmed, bullied, harassed or intimidated? (Include first name, last name and grade if known.)
Your answer
Did you witness the bullying firsthand?
Were there any other witnesses? If so, please list their names here:
Your answer
Describe what happened. Give as much information as you can.
Your answer
Was law enforcement contacted? If yes, then type who was contacted.
Your answer
Reporter Information (Who is reporting this information?)
(OPTIONAL) What is your name? (PLEASE NOTE: Anonymous reports are accepted however they must provide sufficient evidence to justify the commencement of an investigation. Formal disciplinary action may not be based solely on an anonymous complaint.)
Your answer
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