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Bullying Prevention & Intervention
Anonymous Incident Reporting Form

Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.

Reporter Information

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Incident Information

Name of Target (of behavior)
Name(s) of Aggressor(s) (Person(s) engaging in behavior)
Date(s) of Incident(s)
Time(s) of Incident(s)
School
Location(s) of Incident(s)

Witnesses

Please list name(s), role(s) and affiliation(s) of anyone who may have witnessed the incident or have information about it.

Incident Details

Describe the details of the incident (including names of the people involved, what occurred and what each person did and said, including specific words used).
Name of Person Filing this Report (Optional)