AES Anonymous Bullying Incident Report

Anonymous Bullying Incident Report

The District encourages the reporting of bullying incidents to school administrators whenever possible. In cases where confidentiality is a concern, an anonymous incident report may be filled out below.

All forms submitted through these pages remain completely anonymous.

Date of Report*

Answer required for "Date of Report"

Name(s) of alleged target(s) of bullying*

Answer required for "Name(s) of alleged target(s) of bullying"

Name(s) of alleged aggressor(s)*

Answer required for "Name(s) of alleged aggressor(s)"

Name(s) of witness(es)*

Answer required for "Name(s) of witness(es)"

When did the incident occur?*

Answer required for "When did the incident occur?"

What time did the incident occur?*

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

Give a brief description of the incident(s) and/or concerns.*

Answer required for "Give a brief description of the incident(s) and/or concerns."

Did a physical injury result?*

Answer required for "Did a physical injury result?"

Yes, but it did not require attention

Yes, and it required medical attention

Do you know of other incidents of bullying directed at this student?*

Answer required for "Do you know of other incidents of bullying directed at this student?"

Yes

Other:

Name of person reporting incident(s)

(You may report anonymously)

Answer required for "Name of person reporting incident(s)"

Relationship to Student

(Optional)

Answer required for "Relationship to Student"

Email Address

(Optional)

Answer required for "Email Address"

Please fix the highlighted areas below before submitting.

AES Anonymous Bullying Incident Report