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Bully Incident Report
This report will be sent directly to the Jim Hill Office. Please complete by only responding to the questions that you feel comfortable answering and are able to accurately answer. Thank you for standing up for yourself or someone else.
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* Indicates required question
First and Last Name of the Reporter will be Confidential
*
Your answer
Date
*
Your answer
Time
Your answer
Victim
*
Your answer
Bully
*
If you do not know the bully's name describe him/her.
Your answer
Desribe what happened.
*
Your answer
When did the incident take place?
Before School
During School
After School
Unsure
Where did the incident take place?
Classroom
Hall
Lunchroom
Bathroom
School Parking Lot
On the Bus
Online
Other:
Did anyone else witness the bullying?
If yes list in other category.
Yes
No
Unsure
Option 4
Other:
Were you or others physically hurt?
If yes explain in Other category.
Yes
No
Unsure
Other:
Was there damage to anyone's personal property?
Yes
No
Unsure
Have you or the victim missed any school or made changes to your daily routine as a result of the incident(s)?
Yes
No
Unsure
Have you told anyone about the bullying?
Parent
Babysitter
Brother/sister
Other family member
Teachers
Other school staff
Other:
Have you previously filed a bully report(this information is used to determine if retaliation is occurring)?
*
Yes
No
Required
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