Bullying Report Form
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Date of Incident (If you don't know the exact time, feel free to use a descriptor such as before school, during a specific class period, during lunch, after school, night time, passing periods, etc.)
Which choice best describes what happened?
Physical (pushing, shoving, spitting, hitting, kicking, destruction of property, theft, etc.)
Verbal/Non-verbal (name calling, teasing (making fun), spreading false rumors, intimidation, public humiliation, putting down, threats, etc.)
Social/Emotional (rumors, racial slurs, gossip, social exclusion, peer pressure, sexual/religious/racial harassment, etc.)
Cyber Bullying (inappropriate blog or social media posts, stalking, posting inappropriate pictures and comments, etc.)
Other, please specify
Describe, in detail what happened including the witness(es) roles.
The word “target” means the person who was bullied. The word “aggressor” means the person who was doing the bullying. The word “bystander” means people who might have seen or heard the incident as it was happening. This might be someone who saw fight, read something on Facebook, or saw a text between two people. There is often more than one target and one aggressor involved in bullying incidents. Please give us as much information as you can about all the people involved.
Is this a repeated/persistent action of the bully?
Victim/Target's Name (first and last)
Victim/Target School Attending
Accused Name (first and last)
Accused School Attending
Witness #1 Name (first and last)
Witness #1's School Attending
Witness #1's Grade
Witness #1's Gender
Witness #2 Name (first and last)
Witness #2's School Attending
Witness #2's Grade
Witness #2 Gender:
Is there an adult/teacher who could provide more information? Please provide the name:
Reporter's Email Address (optional):
Reporter's Name (optional):
After the report is filed, the administration designated in the building will conduct an investigation and contact you with the outcome. The report will be filed in each building.