District 96: Bullying Incident Report

Associated District 96 School

This will route the information to the proper District 96 administrator.

Please select which best describes your position.

Your Grade Level

If you are a District 96 student, please select your grade level.

Date of the incident:

mm/dd/yyyy

Approximate Time of the Incident:

Please also indicate AM or PM

Location of Incident

Previously Reported?

Yes

Offender's Info

This name field is required in order to investigate reported incidents.

Victim's Info

This name field is required in order to investigate reported incidents.

Witnesses's Info

Incident Description

Please, use concrete and clear wording:

Behaviors Involved Incident

(e.g., stealing, pushing, name calling, etc):

Incident Motivation (if known)

If so, please explain.

District 96 Staff Notified?

If so, list who was notified.

Physical Injuries (if any)

List only those that were a direct result of this incident.

Property Damage (if any)

List only those that were a direct result of this incident.

Contact Information (Optional)

Security Question: 4 + 3 =

Send me a copy of my responses