To be completed by the bullying target, witness, or person with information about an incident of bullying and submitted to the Building Principal’s office. Make readily accessible via website(s) and other publicized designated areas in schools.

Please print and check appropriate boxes.

Name:


Date:


☐ Student   ☐ Parent/Guardian   ☐ Staff   ☐ Other

Indicate here if you prefer to remain anonymous.  ☐Yes      ☐No

Are you the target of the bullying that you are reporting? ☐Yes  ☐No

Date of incident:                    Time of incident:            

Person(s) being reported as targets of bullying: 

Name:


☐ Student  ☐ Staff  

Name:


☐ Student  ☐ Staff  

Name:


☐ Student  ☐ Staff  

Person(s) being reported as aggressors engaged in bullying: 

Name:


☐ Student  ☐ Staff  ☐ Other

Name:


☐ Student  ☐Staff   ☐ Other

Name:


☐ Student  ☐ Staff  ☐ Other

Person(s) who witnessed the bullying: 

Name:


☐ Student  ☐ Staff  ☐ Other

Name:


☐ Student  ☐ Staff  ☐ Other

Name:


☐ Student  ☐ Staff  ☐ Other

Was the incident based on any of these actual or perceived characteristics? (Check all that apply.)
☐ Race
☐ Color
☐ National origin
☐ Sex
☐ Sexual orientation
☐ Gender-related identity
☐ Pregnancy
☐ Gender-related expression
☐ Ancestry
☐ Age
☐ Religion
☐ Physical disability
☐ Mental disability
☐ Order of protection status
☐ Homeless status
☐ Marital status
☐ Parenting status
☐ Physical appearance
☐ Socioeconomic status
☐ Academic status
☐ Military status
☐ Associated with person/group with one or more of the above actual or perceived characteristics
☐ Other                                            
☐ I do not know.

Student(s) were targeted for bullying in the following way(s): (Check all that apply.)
☐ Electronic devices (e.g., Internet, social media platforms, text, email, cyberbullying, etc.)
☐ Written communication (e.g., handwritten notes, other written documents, email, etc.)
☐ Physical act or conduct (e.g., pushing, hitting, destruction of property, stalking, etc.)
☐ Verbal act or conduct (e.g., rumors, lies, name-calling, using derogatory slurs, etc.)
☐ Social (e.g., purposeful exclusion, causing psychological harm, etc.)
☐ Items depicting implied hatred or prejudice were worn, possessed or displayed
☐ Other (please explain):                                    



Student(s) were targeted for bullying in the following place(s): (Check all that apply.)
☐ Classroom
☐ Locker room
☐ Hallway
☐ Extracurricular activity
☐ Cafeteria
☐ Bus
☐ Restroom
☐ Bus stop
☐ Gym
☐ School or related activity or event
☐ Other                                            

Please tell us about the incident in your own words. Use as much detail as possible - what time did the incident(s) take place, who witnessed it, what was said, what types of interactions occurred (physical, written, social, electronic, etc.)




☐  The above information is true and accurate to the best of my knowledge.

Signature:                                                                 Date:                  


UPDATED:    May 23, 2024