Benson Bullying Report

Please complete the form below. Required fields marked with an asterisk *

Today's Date*

Answer required for "Today's Date"

I am a:*

Answer required for "I am a:"

Target of bullying

Witness

Staff Member

Parent/Guardian

Community Member

Other

What date did the incident occur?*

Answer required for "What date did the incident occur?"

Name of Alleged Bully*

Answer required for "Name of Alleged Bully"

What time of day did the incident occur?

Answer required for "What time of day did the incident occur? "

Where did the incident occur? IE: Hallway, Classroom, Bathroom, Lunchroom, Bus Stop, Library, etc.*

Answer required for "Where did the incident occur? IE: Hallway, Classroom, Bathroom, Lunchroom, Bus Stop, Library, etc."

Has the alleged bully done this to the same victim on other occasions?* (yes/no/i don't know)*

Answer required for "Has the alleged bully done this to the same victim on other occasions?* (yes/no/i don't know)"

Please describe the incident that occurred. Be as specific and accurate as possible. **

Answer required for "Please describe the incident that occurred. Be as specific and accurate as possible. *"

Your name / grade (optional)

Answer required for "Your name / grade (optional)"

Please fix the highlighted areas below before submitting.