Bullying Incident Report Form
Thank you for taking time to make this report to PEER Kindness, a nonprofit organization focused on reducing bullying. This form is to be completed by the bullying target, witness, or any person with information about an incident(s) of bullying. Unsure if the behavior is bullying, taunting, teasing, or conflict? No worries as these situations are sometimes tough to distinguish the difference. Complete this form and we can help.

Upon completion, this form will be submitted to PEER Kindness staff only. Staff will be in contact with you within 1 business day of when the report is completed. If you need immediate assistance please call us at 970-901-774; also be sure to report at Safe2Tell-877-542-7233  or https://safe2tell.org/ 
Rev 10/2023
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Date Of Most Recent Incident: *
MM
/
DD
/
YYYY
Is the person making the report (if other, include your  organization):  *
Name of Person making the report: *
Your Contact Information (Phone/Email) *
Name and Age of Student
Contact information for student/parent if different from above. (Please include name, relationship and phone number)
Does the student/parent know this report is being made?
Clear selection
School student attends
Zip Code
Does student receive free/reduced lunch?
Clear selection
Student Ethnicity
Student Gender
Has anyone reported incident to an adult in the school system?
Clear selection
Role of Student in the incident: *
Where did the incident occur? *
What is happening:
Please describe what happened or is happening? Include who was involved. *
What are/were the effects?
Has anyone from the location of event been notified, if yes who?
Did you report to Safe2Tell?                        877-542-7233  or https://safe2tell.org/ *
Is there any additional information you want to share with PEER Kindness?
Submit
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