Bullying Incident Report Form

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Please Fill Out This Form On Any Student Who Displays The Following Bullying Behaviors.

Description Of The Incident That Occurred? *

Physical Aggression - Hitting

Physical Aggression - Kicking

Physical Aggression - Shoving

Physical Aggression - Tripping

Physical Aggression - Pinching

Physical Aggression - Biting

Physical Aggression - Other

Social Aggression (Excluding; Rumors)

Verbal Aggression

Intimidation

Harrassment

Other

Required

Explain Other

Write Information If You Checked Other

What Were Your Postvention Activities? *

(What Was Your Response To The Behavior - Check All That Apply)

Discussion with the Student

Spoke with the School Counselor

Parent Phone Call

Parent Letter

Parent Conference

Consequences (i.e. loss of recess)

Sent to the Principal

Other

Required

Explain Other

Write Information If You Checked Other

Location of Incident *

Gym

Bathroom

Playground

Hallway

Classroom

Bus

Cafeteria

Other Location

Required

Explain Other

Write Information If You Checked Other

Description of Incident *

Please Write Details of What Occurred

Grade of Student *

(For Student Who Is Displaying Bullying Behavior)

Teacher Completing This Form *

Name(s) of Student(s) Displaying Bullying Behavior *

Name(s) of Student(s) - Target of Bullying Behavior *

Date of Incident *

Submit

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