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Bullying Report Form
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* Indicates required question
Type of Incident
*
Bullying
Drugs/Alcohol
Weapons
Other:
Required
Who is the victim? If more than one victim, include all names.
Your answer
Who is the perpetrator (person doing wrong)? If more than one person, include all names.
*
Your answer
Time and date of incident
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Please describe the incident and give all the details possible.
Your answer
Is this an ongoing problem or a one-time incident?
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Where did the bullying happen?
Bus
Gym
Locker room
Lunchroom
In Class
Other:
Have you reported this incident to anyone? If so, to whom? (teacher, parent, administrator, etc.)
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Your name (Optional)
Your answer
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