Gus Birdwell Elementary Bullying Report Form

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Please provide as much information as possible in this report.

Your Role: *

Name of person reporting the incident (optional)

Date of Incident *

YYYY

Time of Incident *

Time

Method of harassment, intimidation, bullying or harm: *

Description of the incident *

Please provide as much information as you can about the incident.

Who was being harassed, intimidated, bullied or harmed? *

What is the victim's age and/or grade? *

Please enter the names of the bullies if you have them. *

Please enter a list of witnesses and their grade level. *

Please read the following statement before submitting your report: *

By submitting this form you acknowledge that the information entered is complete, true, and accurate. Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.

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