Harassment, Intimidation and Bullying Incident Reporting Form
Name of reporting person (optional): _____________________________________________________
I don’t want to share my name
Today’s date: _________________
My school: ________________________________ Your email address (optional): _______________________________ Your phone number (optional): _____________________
Name of the student who was bullied, harassed or intimidated: ________________________________________________________________________________________________
If you told an adult at your school what happened, please give us the name of that person: __________________________________________________________________________
If you know the name(s) of the bullies or their physical description (hair color, eye color, how tall, boy or girl, grade, or what teacher do they have), please tell us the name(s):
If you know on what dates and times the incident(s) happened, please tell us: ____________________________________________________________________________________
Please check the boxes that relate to the incident:
Was the student absent from school because of what happened?
No
Yes. Number of days the student was absent: ___________
Why do you think the harassment, intimidation or bullying happened? _________________________________________________________________________________________
Were there any witnesses? No Yes. If yes, please give us their names: __________________________________________________________________________________
Is there anything else you want to tell us about what happened? _____________________________________________________________________________________________
Referred to: __________________________________________________________________________________________________________________
Elementary Level
Harassment, Intimidation and Bullying Incident Reporting Form
Name of reporting person (optional): _____________________________________________________
I don’t want to share my name
Today’s date: _________________
My school: ________________________________ Your email address (optional): _______________________________ Your phone number (optional): _____________________
Name of the student who was bullied, harassed or intimidated: ________________________________________________________________________________________________
If you told an adult at your school what happened, please give us the name of that person: __________________________________________________________________________
If you know the name(s) of the bullies or their physical description (hair color, eye color, how tall, boy or girl, grade, or what teacher do they have), please tell us the name(s):
If you know on what dates and times the incident(s) happened, please tell us: ____________________________________________________________________________________
Please check the boxes that relate to the incident:
Was the student absent from school because of what happened?
No
Yes. Number of days the student was absent: ___________
Why do you think the harassment, intimidation or bullying happened? _________________________________________________________________________________________
Were there any witnesses? No Yes. If yes, please give us their names: __________________________________________________________________________________
Is there anything else you want to tell us about what happened? _____________________________________________________________________________________________
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