Bullying Incident Reporting Form

Your Name

This line may be left blank if an anonymous report is being made. Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.

Answer Required

Choose whether you are*

Answer Required

Target of the Behavior

Reporter (Not the Target)

Choose whether you are a*

Answer Required

Scholar

Parent

Staff Member (specify role)

Other (specify)

If you need to specify, please do so here:

Answer Required

Your contact information/telephone number:

Answer Required

Choose your campus:*

Answer Required

Sarah D. Ottiwell Campus (515 Belleville Ave)

Frederick Douglass Campus (767 Church St)

If you are a scholar, choose your grade:

Answer Required

1st

2nd

3rd

4th

5th

6th

7th

8th

Name of target of behavior*

(Name and Grade)

Answer Required

Name of Aggressor(s) (Person who engaged in the behavior): *

Answer Required

Date(s) and Time of Incident(s): *

Answer Required

Location of Incident(s) (Be as specific as possible): *

Answer Required

Type of Bullying*

Answer Required

Verbal

Non-verbal

Physical

Cyber-bullying

Other:

8. Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).*

Answer Required

Witnesses (List people who saw the incident or have information about it):

Answer Required

You may upload files here related to this report.

Answer Required

Choose a file or drag it here.

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

Bullying Incident Reporting Form