Bullying Incident Report Form Please complete the following form to report to Administration any incident of bullying or harrassment. Edge High School Bullying Incident Report Form Reporting Person (optional): Your phone number (optional): Your email (optional): Today's Date MM slash DD slash YYYY Targeted Student:(Required) Name of School Adult you've already contacted (if any): Name(s) of buliies (if known): On what dates did the incidents(s) happen (if known): Where did the incident happen?(Required) Classroom Restroom Hallway/Lobby Internet/Social Media Cell phone Email Parking lot Bus/Bus stop During School Activity Off School Property On the wayto/from school Other: Select AllPlease check the box that best describes what the bully did. Please choose all that apply. HItting, kicking, shoving, spitting, hair pulling or throwing something at the student Getting another peroson to hit or harm the student Teasing, name calling, making critical remarks or threatening in person, by phone, by email, etc Putting the student down or making the student a target of jokes Making rude and/or threatening gestures Excluding or rejecting the student Making the student fearful, demaning money or exploiting Spreading harmful rumors or gossip Cyber bullying (bullying by calling, texting, emailing, web posting, etc.) Other Select AllPlease describe the incident:Why do you think the harrassment, intimidation or bullying occured?Were there any witnesses Yes No If yes, please provide their names: Did physical injury result from the is incident? If yes, please describe.Was the target absent from school as a result of the incident? Yes No Iff yes, Please describe.Is there any additional information?For Office Use OnlyDate MM slash DD slash YYYY Received by: Action Taken: Parent/Guardian Contacted Yes No Select one: Resolved Unresolved Referred to: Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
