Report Form for Bullying and School Violence
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Waterloo High School
To be completed by the bullying target, witness, or person with information about an incident of bullying or school violence.  This form will be submitted to the assistant principal.  
Name
Clear selection
Indicate if you prefer to remain anonymous.
Are you the target of the bullying or school violence that you are reporting?
Date of incident:
MM
/
DD
/
YYYY
Time of incident:
Time
:
Person(s) being reported as targets of bullying or school violence:
Please indicate if the person(s) is a student, staff member, or other.
Person(s) being reported as aggressors engaged in bullying or school violence:
Please indicate if the person(s) is a student, staff member, or other.
Person(s) who witnessed the bullying or school violence:
Please indicate if the person(s) is a student, staff member, or other.
Was the incident based on any of these characteristics?
Check all that apply.
Student(s) were targeted for bullying in the following place(s):
Check all that apply.
Please tell us about the incident in your own words.  Use as much detail as possible - what time did the incident(s) take place, who witnessed it, what was said, what types of interactions occurred (physical, written, social, electronic, etc.)
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