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Bullying Incident Report
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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.