Name of Student Target (victim) *
Has the appropriate teacher/coach/bus driver been contacted?
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: *
 Locker Room 
 Parking Lot 
 School Bus 
 Cell Phone 
 At a school sponsored activity or event off school property 
 On the way to/from school 
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 
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?
 Don't Know 
If yes, please provide their names:
Did a physical injury result from this incident?
If yes, please describe:
Was the victim absent from school as a result of the incident?
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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