Name of Student Target (victim) *
Has the appropriate teacher/coach/bus driver been contacted?	Yes   No
If yes, please provide the name(s) of who you contacted:
Name(s) of alledged bully(ies) (if known):
On what date(s) did the incident happen? *
Where did the incident happen? Please choose all that apply: *	Classroom   Hallway   Restroom   Playground   Locker Room   Lunchroom   Parking Lot   School Bus   Internet   Cell Phone   At a school sponsored activity or event off school property   On the way to/from school   Other
If you selected other, please specify
Please select the statement(s) that best describe what happened. Please choose all that apply: *	Hitting, kicking, shoving, spitting, hair pulling or throwing something   Getting another person to hit or harm the student   Teasing, name calling, making critical remarks or threatening, in person or by other means   Demeaning and making the victim of jokes   Making rude and/or threatening gestures   Excluding or rejecting the student   Intimidating (bullying), extorting or exploiting   Spreading harmful rumors or gossip   Cyberbullying   Other
If you selected other, please specify:
What did the alleged bully(ies) say or do? *
Why did the harassment or intimidation (bullying) occur? *
Were there any witnesses?	Yes   No   Don't Know
If yes, please provide their names:
Did a physical injury result from this incident?	Yes   No
If yes, please describe:
Was the victim absent from school as a result of the incident?	Yes   No
If yes, please describe:
Is there any additional information you would like to provide?
Name of person reporting (optional)
Today's date:
Email (optional)
Phone number (optional)

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