Harassment, Intimidation And Bullying Incident Reporting Form
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1Elementary Level
Harassment, Intimidation and Bullying Incident Reporting Form
Name of reporting person (optional): _____________________________________________________
I don’t want to share my name
Today’s date: _________________
My school: ________________________________ Your email address (optional): _______________________________ Your phone number (optional): _____________________
Name of the student who was bullied, harassed or intimidated: ________________________________________________________________________________________________
If you told an adult at your school what happened, please give us the name of that person: __________________________________________________________________________
If you know the name(s) of the bullies or their physical description (hair color, eye color, how tall, boy or girl, grade, or what teacher do they have), please tell us the name(s):
__________________________________________________________________________________________________________________________________________________
If you know on what dates and times the incident(s) happened, please tell us: ____________________________________________________________________________________
Please check the boxes that relate to the incident:
Where did the incident happen?
What happened during the incident?
Was anybody physically hurt?
Classroom
School bus
Taunting, cruelty
Threats using gestures or remarks
No
Hallway
School activity
Teasing , name calling
Share inappropriate images/notes
Yes, medical attention NOT required
Restroom
On the way to/from school
Intimidation, humiliation
Harmful physical contact
Yes, medical attention required
Playground
Off school property
Retaliation
Sexual comments or contact
Please explain: __________________
Locker room
Internet/Social media
Harmful rumors or gossip
Use others to harm a student
_______________________________
Lunchroom
Cell phone
Exclusion, rejection
Demanding money from a student
_______________________________
Cyber bullying
Take advantage of a student
_______________________________
Sport field
Other: __________________
Parking lot
________________________
Other: ________________________________________________
_______________________________
Was the student absent from school because of what happened?
No
Yes. Number of days the student was absent: ___________
Why do you think the harassment, intimidation or bullying happened? _________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Were there any witnesses? No Yes. If yes, please give us their names: __________________________________________________________________________________
Is there anything else you want to tell us about what happened? _____________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
For office use only
Date received: ___________________
Report received by: _____________________________________________
Name of parent/guardian contacted: _____________________________________________
Action taken: ___________________________________________________________________________________________________________________________________________________________________
Check one:
Resolved
Unresolved
Referred to: __________________________________________________________________________________________________________________
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