Bullying Incident Reporting Form
BULLYING INCIDENT REPORTING FORM
PERSON REPORTING INCIDENT (OPTIONAL): DATE:
SCHOOL:
I am a ______Student ______Parent ______Staff Member ______Other (please specify)
Name of person being bullied:______________________________
Location of Incident:______________________________________
Date of Incident:______________
Name of alleged bully:____________________________________
TYPE OF EVENT:
______Physical Bullying - hitting, kicking, shoving, spitting, other physical aggression
______Verbal Bullying - teasing, name calling, put downs, or other behavior (in person or online)
that would hurt others’ feelings or make them feel bad
______Emotional Bullying - starting rumors, telling others to not be friends with someone,
demeaning comments, intimidation, extorting, exploiting or other actions that would cause someone
to be without friends
______Cyber-bullying - using an electronic medium to engage in any previously mentioned bullying
DESCRIPTION OF INCIDENT (please be specific - location, date, time)
Did you witness the event?
List other school community members who witnessed the event:
Signature of Student:_______________________________________ Date:________________
Signature of Staff Member:__________________________________ Date:________________
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