Bullying Incident Reporting Form

Targeted Student:
Age:
Grade:
Alleged Aggressor(s) incl. age and school:
Witness(es):
School:
Incident Date(s):
School Property:
Specify:
School Bus:
School-sponsored event :
Specify:
Electronic Communication :
Specify:
Description of Incident: (Give a brief description of the incident. Include specifics of the interaction(s). Include any information you know about why the incident(s) occurred. ):
Teasing, making critical or demeaning remarks, name calling or threatening (in person or other means):
Threatening to cause harm:
Embarass someone in public:
Maliciously excluding/rejecting from group:
Retaliation:
Defacing clothing or other property:
Intimidation:
Rumors/Lies:
Hitting, kicking, shoving, spitting, hair pulling, throwing:
Making rude or threatening gestures:
Aggression influenced by others:
Other:
Specify:
Did a physical injury result? :
Do you know of other incidents of bullying directed at this student? :
Person Reporting Incident (optional):
Contact phone number (optional):
Relationship to student:
Email Address: (Please enter an email address if you want a confirmation sent to you that your report was successfully submitted.):