Bullying/Harassment Form

Bullying/Harassment Incident Report - STUDENT INCIDENTS

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

Is this a repeat infraction? Yes | No  | Unknown 

Name of School Where Student(s) Attend:

Location of Incident (check all that apply):

Hallway	Restroom	Classroom	Gym	Cafeteria
Playground	Locker Room	Bus Stop	On Bus	Parking Lot
To/From School	After-School Program	School-Sponsered Event	Text/Internet/Social Media
Other:

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
Other:

Cyber-bullying using:

Text Message	Website	Email	Social Media
Other:

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
Other:

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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