STUDENT BULLYING REPORT FORM

STUDENT BULLYING REPORT FORM

Bullying Definition: Any overt acts by a student, or a group students, directed against a student victim with the intent to ridicule, harass, humiliate, intimidate or inflict bodily harm while at school, on school grounds, or at school-sponsored activity. These acts are typically repeated against a student victim over time. Staff/adults may also be considered bullies. Based on this report of alleged bullying, an investigation will take place.
School of Incident*

Little Colonials PreschoolCarrie Downie Elementary SchoolCastle Hills Elementary SchoolHarry O. Eisenberg Elementary SchoolPleasantville Elementary SchoolNew Castle Elementary SchoolSouthern Elementary SchoolKathleen H. Wilbur Elementary SchoolWilmington Manor Elementary SchoolGeorge Read Middle SchoolGunning Bedford Middle SchoolMcCullough Middle SchoolWilliam Penn High SchoolJohn G. Leach School
Reporting Person Name:*

First NameLast Name
Name of victim*

First NameLast Name
Name(s) offender(s):*

First NameLast Name
Name(s) of witnesses/bystanders
Type of Incident (Check all that apply):

RaceAgeSexCreedGenderReligionDisabilitySexual OrientationPhysical AppearanceNational OriginIdentity/ExpressionMarital StatusOther
Type of Incident (Check all that apply):

HallwayCyber(online/text)GymBathroomBusBusStopCafeteriaSchool TripClassroomLocker RoomOther
Who have you reported the incident to: (Check all that apply):

AdministratorCounselorTeacherStudent AdvisorFriendParent/GuardianOther
Explain the incident and provide additional information on the reverse side.
Should be Empty: