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Bullying Report Form

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Bully Report

Please complete the following to report a bullying incident.

Bullying Incident Report Form

Date of Incident: 

Time of Incident: 

Repeat Infraction? Yes    No

Location of Incident: 

Name of Victim(s): 

Name of Student(s) Bullying: 

Name(s) of Witnesses: 

Type of Bullying:

Verbal

Physical: result in injury? Yes No    Reported to School Nurse? Yes No    Reported to Police? Yes No

Relational

Bullying Behaviors (check all that apply):

Shove

Hit, Kicked, Punched    

Threatened

Stole/Damaged Possessions

Excluded    

Taunting  

Graffiti    

False Rumors    

Staring/Leering         

Intimidation 

Inappropriate Touching    

Cyber-bulling using: Text    Email    Website Social Media

Describe the incident: 

Name of Person Reporting (Optional): 

Email (Optional): 

 

    

 

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