Bullying Prevention And Intervention Report Form

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Bullying Prevention and Intervention Report Form
1. Name of Person Filing This Report
Note: Reports may be filed anonymously, but no disciplinary action will be taken against an alleged
aggressor solely on the basis of an anonymous report.
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2. Check whether you are the:
Target of the bullying behavior
Reporter (not target)
3. Check whether you are a:
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Student
Staff member (specify role)
Parent
Administrator
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Other (specify)
4. Your contact information, including telephone number:
5. If a staff member, what is your position?
6. Information about the incident
Name of target of bullying behavior
Name of the aggressor
Date of incident
Time
Location
Witnesses or others who know about the incident (if any), and their role (student, staff, parent, etc.)
Date of incident
Time
Location
Witnesses or others who know about the incident (if any), and their role (student, staff, parent, etc.)
Date of incident
Time
Location
Witnesses or others who know about the incident (if any), and their role (student, staff, parent, etc.)
Describe the details of the incident(s), including the names of all who were involved, what each did,
and specific words and actions:
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Check here if you have attached additional pages for other incidents
 

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