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Bullying Incident Report
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* Indicates required question
Name of person completing this report (optional):
Your answer
Role of person reporting (choose the one that applies):
*
Parent
Student/Victim
Peer/Witness
Name of person being bullied:
*
Your answer
Grade level of person being bullied (if known):
Your answer
School where this incident took place:
*
Freedom Elementary School
Freedom Middle School
Freedom High School
Name of person bullying:
*
Your answer
Grade level of person bullying (if known):
Your answer
Describe the ongoing incident and what has happened.
*
Please provide as much details as possible.
Your answer
Where has this incident(s) occurred?
*
Classroom
Hallway
Bathroom
Lunchroom
Playground
Bus Loading Zone
Other:
Please list witnesses to the events:
*
Your answer
How long has this been going on?
*
Your answer
How have you dealt with this situation up until this point?
*
Your answer
Who have you spoken to about this?
*
Your answer
Who do you want to be aware of the problem?
*
Your answer
What do you want to happen next? (At least 1 choice required)
*
I just want someone to know
I would like an adult to talk to the person who is bullying
I would like an adult to help me develop & practice strategies to solve the problem myself
I would like an adult to meet with both of us to work out the situation
I would like an adult to stop the bullying
Other:
Required
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