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PGS Bullying Incident Reporting Form
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* Indicates required question
Name of Reporter:
*
Your answer
Name of Victim (May be the same as the reporter):
*
Your answer
Name of Student(s) Bullying
*
Your answer
Name(s) of any Bystander(s)
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
Your answer
Is this a repeated behavior?
*
Yes
No
Not sure
Location of Incident
*
Hallway
Restroom
Classroom
Gym
Lunch Room
Playground
Locker Room
Bus Stop
On Bus
Parking Lot
To/From School
School Sponsored Event
Text/Phone/Internet/Social Media
Other:
Required
Type of Bullying
*
Verbal
Physical
Cyber
If you answered Cyber-bullying to the above question, what was the method?
Text Message
Social Media
Email
Other:
If physical did it result in an injury?
Yes
No
Clear selection
Bullying Behaviors (check all that apply)
*
Shoved/Pushed
Hit, Kicked, Punched
Threatened
Stole/Damaged Possessions
Told Lies or False Rumors
Inappropriate touching
Writing/Graffiti
Demeaning Comments
Taunting/ridiculing
Intimidation/Extortion
Staring/Leering
Excluded
Other:
Required
Describe the incident
*
Your answer
Why did the bullying incident occur?
Your answer
Did you inform any PGS staff members of this incident?
*
Yes
No
If you answered yes to the above question, please list the staff member(s).
Your answer
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