Fillable Printable Bullying Incident Reporting Form Sample

Bullying Incident Reporting Form Sample

BULLYING INCIDENT REPORT FORM

Date of Incident: ________________ T i me of Incident: ____________ Re peat infraction? YES NO

Location of Incident (circ l e all that apply):

Hallway Restroom Classroom Gym Lunch Room Playground Locker Room Bus Stop On Bus Parking Lot

To/From School After School Program School Sponsored Event Text/Phone/Internet/Social Media Other: ______________

Name of victim(s): Name of student(s) bullying: Name(s) of witnesses/bysta nders:

__________________________ __________________________ ________ __________________

__________________________ __________________________ ___________________ _______

Type of Bullying:

□ Verbal

□ Physical: Result in inj ury? YES NO Reported to School Nurse? YES NO Repor ted to Police? YES NO

□ Relational

Bullying Behaviors (circle all that apply):

Shoved/Pushed Hit, Kicked, Punched Threatened Stole/Damaged Possessions

Excluded Taunting/ridiculing Writing/Graffiti Told Lies or False Rumors

Staring/Leering Intimidation/Extortion Demeaning Comments Inappropriate touching

Cyber-bullying using: Text messages Website Email Other: _____________________________________

Racial, Sexual, Religious or Disability Circle one and describe: ______________________________________________________

Reported to school by (circle all that apply):

Teacher Student Bystander Victim/Target Parent Bus Driver Anonymous Other: _______________________________

Describe the incident:

_____________________________________________________________________________________

Physical Evidence? Notes Email Graffiti Video/audio Website Other:_______________________________

Actions Taken (see Protocol for Guidelines):

Consequences: ______________________ ____ _________ ____ _________ ____ _________ ____ _________ ____ _________ ____ _

Remediation: ______________________________________________________________________________________________

Referral for additional support services: _________________________________________________________________________

Parent Contact: Date ____________ Time ____________ Person making contact: _____________________________________

Result: ________________________________________________________________________________________

Tod ay’s Date: ______ ___ Reported by: ______ _______________ ___ Signatu re: ___________________________

Bullying Incident Follow-Up

Follow-up Conference Date: Time:

Conducted by:

People present:

 Administrator______________  Social Worker___________  Counselor___________  Teacher_________________

 Student __________________  Parent _______________  Parent ______________  Witnesses ______________

 School Psychologist  Other ________________________________________________________________

According to student, situation is: Better Worse No difference

Comments:

Parent Contact: Date: Time: Person making contact:

Additional Actions / Notes: