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Bullying Report Form (Wagoner)
This form should be used to report a bullying incident that has been witnessed or experienced. Provide as much detail as you can. You may identify yourself if you want, but it is not necessary, you may remain anonymous. Thank you.
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* Indicates required question
Have you ever reported an incident before?
*
Yes
No
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
*
Time
:
AM
PM
Is This a Repeat Infraction?
*
Yes
No
I Don't Know
Place Incident Occurred
*
Your answer
How often has this bullying occurred ? (to your knowledge)
*
Your answer
How long did this incident take place?
*
Your answer
Who was the bully?
*
Your answer
Who was the victim?
*
Your answer
If there were any bystanders, who were they?
*
Your answer
Please describe the incident using clear, concrete language.
*
Your answer
What behaviors were involved in the incident?(e.g. pushing, hitting, stealing, threatening, calling names, etc.)
*
Your answer
Were staff or an adult informed of the incident
*
Yes
No
Maybe
Who was informed?
*
Your answer
Were there any injuries?
Your answer
Was there any property damage?
Your answer
Reported by:
Your answer
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