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Bullying Incident Report Form
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* Indicates required question
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
*
Time
:
AM
PM
Repeat Infraction?
*
Choose
Yes
No
Location of Incident (Select all that apply)
*
Hallway
Restroom
Classroom
Gym
Lunch Room
Playground
Locker Room
Bus Stop
On Bus
Parking Lot
To/From School
After School Program
School Sponsored Event
Text/Phone/Internet/Social Media
Other:
Required
Name of victim(s):
*
Your answer
Name of student(s) bullying:
*
Your answer
Name(s) of witnesses/bystanders:
(If none, please type none.)
*
Your answer
Type of Bullying
*
Verbal
Physical
Relational
Required
If Physical, did it result in injury?
Choose
Yes
No
If Physical, was it report to School Nurse?
Choose
Yes
No
If Physical, was it report to Police?
Choose
Yes
No
Bullying Behavior (Select all that apply)
*
Shoved/pushed
Hit, Kicked, Punched
Threatened
Stole/Damaged Possessions
Excluded
Taunting/ridiculing
Writing/Graffiti
Told Lies/False Rumors
Staring/Leering
Intimidation/Extortion
Demeaning Comments
Inappropriate Touching
Cyber-bullying
Racial, Sexual, Religious or Disability
Other:
Required
If Cyber-bullying, which of the following was used?
Text Message
Website
Email
Other:
If Racial, Sexual, Religious or Disability in nature please describe below.
Your answer
Reported to school by:
*
Teacher
Student
Bystander
Victim/Target
Parent
Bus Driver
Anonymous
Other:
Required
Please provide any additional information that you feel needs to be reported.
Your answer
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