Bullying Incident Report Form
You have the right to remain anonymous when filling out this report. It is important to provide the name of the alleged victim, alleged bully, date, time, and location of the alleged incident and what actions were taken to help with the investigation of this incident and the supervision of students.
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Date of Incident: *
Time of Incident: *
Time
:
Location of incident *
Name of Victim(s): *
Name of student(s) bullying: *
Name(s) of witnesses, if any
Type of Bullying: *
If it was Physical Bullying: (choose all that applies)
Bullying Behavior: *
Required
Reported to: *
Required
Describe the incident: *
Physical evidence:
Today's Date: *
MM
/
DD
/
YYYY
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