Name of student target (victim)
Name of victim's school:
Has this incident been reported to a school employee?
If yes, please provide the name(s) of who you contacted:
Name(s) of alleged bully(ies) (if known):
On what date did the incident happen?
Where did the incident happen? Please choose all that apply:*
If you selected other, please specify:
Please select the statement(s) that best describe what happened. Please choose all that apply:
Please specify if you selected other:
What did the alleged bully(ies) say or do?
Were there any witnesses (if known)?
Did a physical injury result from this incident?
Was the victim absent from school as a result of the incident?
Is there any additional information you would like to provide?