Anonymous Bullying Incident Report
The District encourages the reporting of bullying incidents to school administrators whenever possible. In cases where confidentiality is a concern, an anonymous incident report may be filled out below.
Date of Report *
MM
/
DD
/
YYYY
Name(s) of alleged target(s) of bullying *
Your answer
Name(s) of alleged aggressor(s) *
Your answer
Name(s) of witness(es) *
Your answer
When did the incident(s) occur? *
MM
/
DD
/
YYYY
Time
:
Where did the incident(s) occur? *
Your answer
School Name *
Your answer
Please check the box or boxes next to the statement(s) that best describe what happened (choose all that apply) *
Required
Give a brief description of the incident(s) and/or concerns. *
Your answer
Did a physical injury result? *
Do you know of other incidents of bullying directed at this student? *
Name of person reporting incident(s)
You may report anonymously
Your answer
Relationship to Student (Optional)
Your answer
Email Address (Optional)
Your answer
Submit
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This form was created inside of Lammersville Unified School District.