Bullying Investigation Form - Louisiana Department Of Education
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4BuLLying investigation form
Directions: In accordance with Act 861 of the 2012 Legislative Session, this form is to be used to investigate and document the
details of each reported incident of bullying that occurred on school property; at a school-sponsored activity or event off school
property; on a school bus; or on the way to or from school.
Date of Report:
School Name:
District:
Date of incident:
Time of incident (if known):
INTeRvIewS CoNDuCTeD:
(Check all that apply and attach a separate sheet if necessary.)
Interviewed Reporter
Name:
Date:
Description of alleged bullying:
Interviewed Alleged victim(s)
Name(s):
Date:
Description of alleged bullying:
Interviewed Alleged offender(s)
Name(s):
Date:
Description of alleged bullying:
Interviewed witness(es)
Name:
Date:
Name:
Date:
Name:
Date:
Description of alleged bullying:
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Louisiana Department of eDucation POST OFFICE BOX 94064 | BaTOn ROugE, La 70804-9064 | 1.877.453.2721 |
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