REPORT OF SUSPECTED BULLYING BEHAVIORS OR TEEN DATING VIOLENCE
( School Employees Should File with the School Principal ) ( Parents and Students May File with the School Principal or any other School Employee )
Name of Person Completing Report : ________________________________________________________
Date : __________________
Target ( s ) of Behaviors / Violence : ___________________________________________________________________________ _________________
Relationship of Reporter to Target ( self , parent , teacher , peer , etc .): ___________________________________________________________________________ ___________________________________________________________________________ ____________________________________
Report Filed Against :
________________________________________________________________________
Date of Incident ( s ): _________________________________________________________________________
Location ( s ):______________________________________
Time : _______________
Describe the basis for your report . Include information about the incident , participants , background to the incident , and any attempts you have made to resolve the problem . Please note relevant dates , times and places .
______________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
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