Part 1: Basic Information

• Your Name: ___________________________________________

• Your Role:

• Parent

• Student

• Teacher/Staff

• Other: ___________________________________________

• Date of Incident Report: ___________________________________________

• Contact Information (Phone/Email): ___________________________________________

Part 2: Information About the Bullying Incident

1. Date of Incident: ___________________________________________

2. Time of Incident (If Known): ___________________________________________

3. Location of Incident (Check All That Apply):

• Classroom

• Hallway

• Cafeteria

• Playground

• School Bus

• Online (e.g., social media, texting, apps)

• Other: ___________________________________________

4. Type of Bullying (Check All That Apply):

• Physical (e.g., hitting, kicking, pushing)

• Verbal (e.g., name-calling, teasing)

• Social/Relational (e.g., spreading rumors, exclusion)

• Cyberbullying (e.g., online harassment, threats)

• Damage to Property (e.g., destroying or stealing personal items)

5. Brief Description of the Incident (Include Key Details):
   

Part 3: People Involved

1. Name(s) of Person(s) Being Bullied:
   

2. Name(s) of Alleged Bully/Bullies (If Known):
   

3. Were There Witnesses?

• Yes

• No

4. If Yes, List Witness Names (If Known):

Part 4: Action Steps

1. Did You Report the Incident to a Teacher, Staff Member, or Authority Figure?

• Yes

• No

2. If Yes, Whom Did You Report to? (Name/Role):
   

3. What Immediate Action (If Any) Was Taken?
   

4. What Additional Support or Follow-Up Are You Requesting?
   

Part 5: Evidence (Optional)

• List Attached Evidence (If Applicable):

• Photos

• Screenshots of Online Messages/Posts

• Notes or Letters

• Medical Reports

• Other: ___________________________________________

Signature

I certify that the information provided in this report is accurate to the best of my knowledge.
Signature: ___________________________________________
Date: ___________________________________________