Bullying Report Form (Wagoner)
This form should be used to report a bullying incident that has been witnessed or experienced. Provide as much detail as you can. You may identify yourself if you want, but it is not necessary, you may remain anonymous. Thank you.

Have you ever reported an incident before? *
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Is This a Repeat Infraction? *
Place Incident Occurred *
How often has this bullying occurred ? (to your knowledge) *
How long did this incident take place? *
Who was the bully? *
Who was the victim? *
If there were any bystanders, who were they? *
Please describe the incident using clear, concrete language. *
What behaviors were involved in the incident?(e.g. pushing, hitting, stealing, threatening, calling names, etc.) *
Were staff or an adult informed of the incident *
Who was informed? *
Were there any injuries?
Was there any property damage?
Reported by:
Submit
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