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Bullying Prevention and Intervention Incident Reporting Form
I. REPORT
1. Name of Reporter/Person Filing the Report: __________________________________________________________
(Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.)
2. Check whether you are the: Target of the behavior Reporter (not the target)
3. Check whether you are a: Student Staff member (specify role) ________________________________
Parent Administrator Other (specify) ______________________
Your contact information/telephone number:_________________________________________________________
4. If student, state your school: _________________________________________________ Grade: _____________
5. If staff member, state your school or work site: ______________________________________________________
6. Information about the Incident(s):
Name(s) of alleged Target(s) (of behavior): __________________________________________________________
Name(s) of alleged Aggressor(s) (Person who engaged in the behavior): ___________________________________
Date(s) of Incident(s): ___________________________________________________________________________
Time(s) When Incident(s) Occurred: ________________________________________________________________
Location(s) of Incident(s) (Be as specific as possible): __________________________________________________
7. Alleged Witness(es) (List people who saw the incident or have information about it):
Name: _________________________________________ • Student • Staff • Other ________________________
Name: _________________________________________ • Student • Staff • Other ________________________
Name: _________________________________________ • Student • Staff • Other ________________________
8. Describe the details of the incident(s): include names of people involved, what occurred, and what each person did and said, including specific words used). Please use additional space on the back if necessary.