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Anonymous Bullying Incident Report
Please complete the bullying incident report. This report is anonymous. If you have an immediate concern, please contact your school's principal.
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* Indicates required question
I am a:
*
Choose
Parent
Student
Family Member
During this incident I was a:
*
Choose
Victim
Bystander
Type the name of the student(s) who are bullying and the school they attend.
*
Your answer
What grade are you in?
*
Choose
K
1
2
3
4
5
6
7
8
What is the name of the student you would like to report?
*
Your answer
If you do not know the name of the student, please describe the person.
Your answer
Where did this incident take place?
*
Choose
In class
In school
Lunch room
Locker room
Outside of school
Online (cyberbulling)
Please describe the incident.
*
Your answer
Were there witnesses to this incident? (if known)
*
Choose
Yes
No
What are the names of the witnesses?
Your answer
Please rate the severity of this incident.
*
1 being minor incident but unacceptable to 5 being major incident
Minor
1
2
3
4
5
Major
Please describe the frequency with which this type of incident occurs.
*
Choose
Once
Rarely (2-4 times)
On a regular basis
Everyday
Would you like to speak with a counselor?
*
You must add your name below if you want a counselor to follow up with you.
Choose
Yes
No
What is your name (optional)
Your answer
What else would you like us to know about this incident? (optional)
Your answer
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