Bullying Prevention and Intervention Incident Reporting Form

Name may be left blank if an anonymous report is being made.  (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.)

The incident will be investigated even if an anonymous report is made.
This is the person or persons who you believe is the victim of bullying
This is the name or names of the bully or bullies
Try ot be as specific as possible
examples: "playground" or "Room 101" or "Mrs. Smith's math class"
Please list people who saw the incident or who may have information about the incident
Please include names of people involved, what occurred, and what each person did and said, including specific words used
This is optional; reports may be filed anonymously