Bullying Incident Report

1.	Date of Incident:*
	mm/dd/yyyy

2.	Time of Incident:*

3.	Name of Victim:*

4.	Person Reporting the Incident:*

5.	Name of Student(s) Bullying:*

6.	Name of Witness(es):*

7.	Location of Incident:* Select at least 1 and no more than 3.
	Hallway  Restroom  Classroom  Gymnasium  Locker Room   Cafeteria  School Bus  Play Ground   Other, please specify

8.	Type of Bullying:*
	Verbal  Physical  Relational  Cyber   Other, please specify

9.	Bullying Behaviors:* Select at least 1 and no more than 5.
	Shoved/Pushed  Excluded  Staring/Leering  Cyber-bullying  Hit/Kicked/Punched   Threatened  Stole/Damaged Possessions  Writing/Graffit  Taunting/Ridicule  Intimidation/Extortion   Demeaning Comments  Spreading Rumors  Inappropriate Touching  Racial  Religious   Disability   Other, please specify

10.	Please describe the incident:*