Fillable Printable Bullying Incident Reporting Form

Bullying Incident Reporting Form

BULLYING INCIDENT REPORTING FORM

PERSON REPORTING INCIDENT (OPTIONAL): DATE:

SCHOOL:

I am a ______Student ______Parent ______Staff Member ______Other (please specify)

Name of person being bullied:______________________________

Location of Incident:______________________________________

Date of Incident:______________

Name of alleged bully:____________________________________

TYPE OF EVENT:

______Physical Bullying - hitting, kicking, shoving, spitting, other physical aggression

______Verbal Bullying - teasing, name calling, put downs, or other behavior (in person or online)

that would hurt others’ feelings or make them feel bad

______Emotional Bullying - starting rumors, telling others to not be friends with someone,

demeaning comments, intimidation, extorting, exploiting or other actions that would cause someone

to be without friends

______Cyber-bullying - using an electronic medium to engage in any previously mentioned bullying

DESCRIPTION OF INCIDENT (please be specific - location, date, time)

Did you witness the event?

List other school community members who witnessed the event:

Signature of Student:_______________________________________ Date:________________

Signature of Staff Member:__________________________________ Date:________________