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.):