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.)

1. If you wish to be contacted, please enter the best phone number and time to reach you.

The incident will be investigated even if an anonymous report is made.

3. Check whether you are the: *

Target of the behavior

Reporter/Witness (not the target)

4. Name of the target *

This is the person or persons who you believe is the victim of bullying

5. Which school does the target attend or where did the incident take place *

6. Name of the aggressor *

This is the name or names of the bully or bullies

7. Date(s) of action witnessed

Try ot be as specific as possible

8. Time when incident took place

9. Location of incident

examples: "playground" or "Room 101" or "Mrs. Smith's math class"

10. Witnesses to incident

Please list people who saw the incident or who may have information about the incident

11. Describe the details of the incident

Please include names of people involved, what occurred, and what each person did and said, including specific words used

12. Your name

This is optional; reports may be filed anonymously

Leave this field blank