Report of Bullying/Harassment Incident



*Name of School:
*Date of Report:
IMMEDIATE DANGER:
Your Name:
*Grade:
*Your Gender:
*Gender of the Victim:
*What happened?:
*Where did it happen?:
*Who was involved/witnessed the incident?:
*Have you spoken to anyone about this incident?:
If yes, who?:
*Is this the first time something like this has ever happened to the person that was bullied?:
What would you like to see as a consequence of the behavior stated above?: