Bullying/Harassment Form

Custom Form

Bullying/Harassment Incident Report - STUDENT INCIDENTS

Today's Date:Date of Incident:Time of Incident:

Is this a repeat infraction? Yes | No  | Unknown 

Name of School Where Student(s) Attend:

Location of Incident (check all that apply):

PlaygroundLocker RoomBus StopOn BusParking Lot
To/From SchoolAfter-School ProgramSchool-Sponsered EventText/Internet/Social Media 
Name of Victim(s):Name of Offender(s):Name(s) of Witness(es)/bystander(s):

Type of Incident (Check Appropriate Boxes)

 Verbal Physical Relational (damaging someone's relationship or social status)
Resulted in Injury? YES / NO Required Medical Attention? YES / NO Reported to Police? YES / NO

Bullying Behaviors (Check all that apply):

Shoved/Pushed Hit/Kicked/Punched Threatened
Stole/Damaged Possessions Taunting/Ridiculing Writing/Graffiti
Told Lies/Rumors Staring/Leering Intimidation/Extortion
Demeaning Comments Inappropriate Touching  

Cyber-bullying using:

Text Message Website Email Social Media

Harassment (Check Purpose):

Disability Sex Race, Color, or National Origin Sexual Orientation Religion

Describe the incident (attach a separate sheet of paper if necessary):

Do you have any physical evidence?

Notes Graffiti Email Video/Audio Website

Name of Person Completing Report (OPTIONAL)

May we contact you for further information?YES / NO

If Yes, which is the best way to contact you?PHONE / TEXT / EMAIL

Phone Number: HOME / CELL

Email Address:

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