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 for "Your Name"

Choose whether you are*

Answer required for "Choose whether you are"

Target of the Behavior

Reporter (Not the Target)

Choose whether you are a*

Answer required for "Choose whether you are a"

Scholar

Parent

Staff Member (specify role)

Other (specify)

If you need to specify, please do so here:

Answer required for "If you need to specify, please do so here:"

Your contact information/telephone number:

Answer required for "Your contact information/telephone number:"

Choose your campus:*

Answer required for "Choose your campus:"

Sarah D. Ottiwell Campus (515 Belleville Ave)

Frederick Douglass Campus (767 Church St)

If you are a scholar, choose your grade:

Answer required for "If you are a scholar, choose your grade:"

1st

2nd

3rd

4th

5th

6th

7th

8th

Name of target of behavior*

(Name and Grade)

Answer required for "Name of target of behavior"

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

Answer required for "Name of Aggressor(s) (Person who engaged in the behavior): "

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

Answer required for "Date(s) and Time of Incident(s): "

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

Answer required for "Location of Incident(s) (Be as specific as possible): "

Type of Bullying*

Answer required for "Type of Bullying"

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 for "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)."

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

Answer required for "Witnesses (List people who saw the incident or have information about it):"

Please fix the highlighted areas below before submitting.

Bullying Incident Reporting Form