Bullying Incident Report

1.	Today's Date
	mm/dd/yyyy

2.	Date of Incident
	mm/dd/yyyy

3.	I was:
	A witness of bullying    Bullied    Other, please specify

4.	Where did this incident take place?

5.	Names and roles of people involved (e.g. witness, victim, participant, etc.)

6.	Description (please provide as many details as possible)

7.	Does an adult know about this incident?
	-- None --Yes No

8.	If so, who is the adult?

9.	My name is (THIS FIELD IS OPTIONAL)

10.	My grade is (THIS FIELD IS OPTIONAL)

11.	What is the phone number that you can be contacted at? (THIS FIELD IS OPTIONAL)