Today’s Date:            

Person Filing Report:    (Optional)  

Name of Victim:        

Time and Date of Bullying Incident:

Location of Bullying Incident:

Describe the incident with as much detail as possible:

Who was / were the perpetrator(s) (Who did the bullying?)

Names of Potential Witnesses:

Would the victim like to talk to someone at Rochambeau about this incident? Yes No

Would the person filing this report like to talk to someone at Rochambeau about this incident in further detail?

  Yes No      If yes, please list your name and phone number:

Please Note: The information given on this incident report is strictly confidential.

Please Note: Knowingly giving false information violates school policy.  

Rochambeau Middle School
Copyright © 2006 [Region 15]. All rights reserved.
Revised: March 16, 2008