Bullying Prevention Form
Please complete this form to report a bullying incident.
Name of person filing report
Name of student(s) being targeted
Grade level or age of targeted student(s)
Please explain in your own words what happened.
Please list the names(s) of the accused bullies or provide a description of them.
Where did the bullying take place? Please be specific. (On the school bus, in the hallway, at lunch, etc.)
When did the bullying take place? Please be specific. (In 5th period gym class, during recess, etc.)
Has this person bullied you or your student before?
If yes, did you complete/report the incident?
Please list the approximate date you completed the previous report.
What administrative action (if any) was taken?
To your knowledge was parent communication made?
To your knowledge were faculty members involved?
If yes, please list names of faculty members.