Bullying Incident Reporting Form

Today's Date Question is mandatory

(MM/DD/YYYY)

Campus

Name of person completing form (optional)

Relationship to alleged victim/offender (optional)

Contact Number (optional)

Name of student that committed the threat and grade level Question is mandatory

Intended target/victim: #1 Name and Grade Question is mandatory

Intended target/victim: #2 Name and Grade

What is the current location of the intended target?

Name(s) of witnesses to incident (if applicable)

Date of the threat Question is mandatory

(MM/DD/YYYY)

Time of the threat Question is mandatory

Where did the threat occur (be specific)? Question is mandatory

What type of threat or incident occured Question is mandatory

Incident Description Question is mandatory

Has the incident been reported to an adult or staff member at school? Question is mandatory

Yes