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Bully Incident Report
Reporter Name
First Name
Last Name
Email
Verify Email
Contact Information
Phone
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Bullying Incident Details
Date of Incident
*
(mm/dd/yyyy)
School Name, City, State
Location of Incident (check all that apply)
Classroom
Hallway
Gym
Lunch Room
Restroom
Playground
Bus Stop
On Bus
To/From School
After School Program
School Sponsored Event
Text/Phone/Social Media
Name of victim(s):
Name of student(s) bullying:
Names(s) of witnesses/bystanders:
Type of Bullying:
Verbal
Physical (Please include details in the story box)
Relational
Bullying Behaviors (check all that apply):
Shoved/Pushed
Hit, Kicked, Punched
Threatened
Stole/Damaged Possessions
Excluded
Taunting/Ridiculing
Demeaning Comments
Inappropriate touching
Cyberbullying
Racial, Sexual, Religious or Diability
School Staff Reported To:
Principal
Vice Principal
Teacher
Bus Driver
Counselor
Volunteer
Share Your Story- Describe the incident:
Support Requested
Contact My School
Share My Story on Social Media
Refer me to a Counselor/Attorney
Parent Advocacy Training
