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Bullying Report Form
Please complete the entire form, responding to all the questions as accurately as possible. If you are unsure of the answer to any questions, please indicate so.
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Describe what happened/ what is happening:
Your answer
When did it happen?
Before School
After School
Unsure
What date did it happen on?
Your answer
What time did it happen, morning or afternoon?
Morning
Afternoon
Where did it happen?
School Building
On the playground
Parking Lot
On the school bus
Online
At a school event
Unsure
Other
Add details about the location (which classroom, which school event, etc...)
Your answer
Who was committing the bullying (if you are unsure of the bully's name(s) describe him/her)
Your answer
How did you learn of the incident?
Witnessed it
Received an oral report from the victim
Received a written report from the victim (please turn that into principal)
Received an oral report from bystander
Received a written report from bystander (please turn that into principal)
Received an oral report from community member
Received a written report from community member (please turn that into principal)
Received an oral report from perpetrator
Received a written report from perpretator (please turn that into principal)
Suspected bullying as a result of changes in a student's behavior
Did anyone else witness the bullying?
Yes (please list below)
No
Unsure
Please list names of witnesses and/or anyone that may have information about the incident.
Your answer
Were students/others physically hurt (please explain)
Your answer
Was there damage to anyone's personal property?
Your answer
Have you noticed a change in the victim's routine (e.g., attendance patterns changed, grades dropped, avoids certain locations in the school)? Please explain.
Your answer
If the bullying ocurred online is there evidence that it was/has caused:
A substantial disruption to the educational environment (e.g., staff prevented from carrying out duties, computer networks shut down, change in attendance patterns)
A true threat (a statement that, in light of the circumstances, a reasonable person would perceive as a serious expression of an intent to inflict harm)
Unsure
Other:
If other please explain
Your answer
In your view, was the incident motivated by any of the following traits (actual or perceived)?
Race
Color
Religion
Sex (includes sexual orientation)
Socioeconomic Status
N/A
Unsure
Was the incident an act of retaliation against an individual who filed a previous bullying report and/or participated in an investigation?
Yes
No
Unsure
Clear selection
Have you reported the incident to administration?
Yes
No
Clear selection
Have you reported the incident to law enforcement?
Yes
No
Clear selection
Your name
Your answer
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