Bullying Incident Report Form
**Deshler Public Schools takes all bullying incidents seriously and strives to achieve a safe environment for all students. This report will be looked over carefully and we will do our best to see what changes can be made. If a consequence is deemed necessary, that will also be taken into consideration.
Name: (held in confidentiality)
Your answer
Date of Incident:
MM
/
DD
/
YYYY
Time of Incident:
Time
:
Repeat Infraction?
Location of Incident (check all that apply):
Required
Name of victims:
Your answer
Name of student(s) bullying:
Your answer
Name(s) of witnesses/bystanders:
Your answer
Bullying behaviors (check all that apply):
Required
Describe Incident:
Your answer
Physical Evidence?
Submit
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