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Incident Information
Reported By
Person Reporting Incident (may report anonymously)
I am a
Student
Parent/Caregiver
Teacher/Staff
Volunteer
Phone
Email
Date Incident Occurred
(mm-dd-yyyy)
Name of target of the bullying incident (student being bullied):
Name of alleged offender
Type of bullying (check all that apply)
Verbal
Physical
Social/Relational
Written or Electronic
Brief explanation of incident
Where did the bullying happen (Location)
Did a physical injury result from this incident
No
Yes, but it did not require medical attention
Yes, it did require medical attention
Medical Attention Required
Was the target of the incident absent from school
Yes
No
If yes, how many days was the student absent as a result from this incident
Any other information you would like to provide to help in our investigation
Signature
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Date
(mm-dd-yyyy)
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