1. | Today's date |
| mm/dd/yyyy |
2. | My name is (This field is optional) |
| |
3. | Grade (This field is optional) |
| |
4. | What is the phone number that you can be contacted at? (This field is optional) |
| |
5. | Date of incident |
| mm/dd/yyyy |
6 | I was: Bullied A witness of bullying Other, please specify |
7. | Where did this incident take place? |
8. | Names of the people involved, school and their role (W-witness, V=victim, P=participant, O=other) |
| | Name | School | Role |
| Person 1 | | | |
| Person 2 | | | |
| Person 3 | | | |
| Person 4 | | | |
| Person 5 | | | |
| Person 6 | | | |
| Person 7 | | | |
| Person 8 | | | |
9. | Description - give as many details as possible. |
10. | Does an adult know about this incident? Yes No |
11. | Who is the adult? |