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Bullying/Retaliation Incident Report
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Name of the person filling out this report
*You do NOT have to put your name on this report if you wish to remain anonymous
Your answer
Are you the target of the behavior (are you being bullied or harassed)?
Yes
No
Clear selection
Are you a
Student
Parent
Other
Clear selection
How can we contact you?
(Phone number, email address, physical address?)
Your answer
Who is being targeted?
Your answer
Who is the aggressor?
Your answer
When did this incident occur?
MM
/
DD
/
YYYY
Where did this incident occur?
Your answer
Are there any witnesses to the incident?
Your answer
What happened? (Be as SPECIFIC as possible)
Your answer
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