Ver.2/2021

Alleged Bullying/Harassment/Aggression Incident Form

1. Name of Reporter: _____________________________ Date of Report:_______________________

2. Information about Incident:

    Number of Targets Involved: _____________

    Name and Grade of Target(s) of behavior:  ___________________________________________________

  ___________________________________________________________________________________

Name and Grade of Student(s) Initiating Alleged Bullying/Harassment:

_____________________________________________________________________________________

 _____________________________________________________________________________________

 Date of Incident: ______________________          Time of Incident: _______________________

(If more than one identified:)

Date of Incident: ______________________           Time of Incident: _______________________

Date of Incident: ______________________           Time of Incident: _______________________

 Incident Location(s) (be as specific as possible): __________________________________________________________________________________________

__________________________________________________________________________________________

3. Witnesses: (List people who saw the incident or have relevant information about the incident):

Name & Grade ________________________________     

Name & Grade ________________________________

Name & Grade ________________________________     

 Name & Grade ________________________________

4. Please check all behaviors that apply to this investigation:

___ Name calling/Demeaning Comments (examples____________________________________________________________________)

___ Stealing (What was stolen? _____________________________________________________________________________)

 ___ Spitting                                                            

___ Threatening

(please descibe____________________________________________________________________)

___ physical aggression

(please describe:  ________________________________________________________________)

___ Intimidation/extort

(please describe __________________________________________________________________)

___ Damaging property

         (What was damaged?______________________________________________________________)

___ Inappropriate physical contact

(please describe ____________________________________________________________________)   

___  Writing/graffiti

(What was written? ________________________________________________________________)

___ Exclusion

(please describe ___________________________________________________________________)

___ Stalking

___ Taunting/ridiculing

 (please describe __________________________________________________________________)          

___ Flashing a weapon

(please describe ___________________________________________________________________)

5. Please check off any supporting information: 

Physical evidence:    Graffiti _____ Notes _____ E-mail _____ Web sites _____

Pictures ____  Audio/Videotape ______    ____ digital (texting, Instagram, etc.)

Other _____ (please describe______________________________________________)

Please provide any physical evidence to the investigators.

6. Describe the details of the incident(s) (the names of person involved, what occurred, and what each person did and said, including specific words used; use additional  paper, if necessary):

Reporting person signature:   _____________________________  Date: _________________

Received By:  ___________________________________________ Date: _________________

***End of Alleged Bullying/Harassment/Aggression Reporting Form***