Chenango Forks Central School District

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Chenango Forks Central School District
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Bullying Incident Reporting Form

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Bullying Incident Reporting Form

What was the date of this incident?

About the Person Reporting:

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Name of Student Targeted

Student Targeted Grade:

Student TargetedSchool:

Name of Alleged Aggressor(s) (if known):

Alleged Aggressor(s) Age:

Alleged Aggressor(s) Grade:

Alleged Aggressor(s) School:

Name of Witnesses (if known):

Exact Location of Incident(s):

Briefly Describe Injury:

What did the aggressor(s) say or do? (be specific)

Have there been similar bullying incidents involving the aggressor and targeted student in the past?

If yes, briefly describe:

If the bullying involved electronic communications, is documentation available?

If yes, describe form of documentation

Was personal property stolen or damaged as a result of the incident?

Please describe item(s):

Is there any additional information you would like to provide?

E-mail address (if preferred method of communication):

Phone Number:

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