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High School Bullying/Harassment Incident Form


Bullying/Harassment Incident Reporting Form

Bullying is a type of violence that occurs whenever a student intentionally, repeatedly, and over time inflicts or threatens to inflict physical or emotional injury or discomfort on another's body, feelings, or possessions, and substantially interferes with a student's academic performance or ability to participate in any school related activity.

If the incident meets this definition, please complete this form.

Date of Incident                                                    Time

Person Completing Form 

Location of Incident (Check all that apply):

Hallway            Gym                   Locker Room        Parking Lot

Restroom         Lunch Room      Bus Stop               Off Campus   

Classroom       Playground         On Bus

Reported to School by (Check all that apply):

Teacher        Student            Bystander           Target

Parent          Bus Driver        Anonymous        Other

When Did the Incident Happen (Check all that apply):

To/From School        After School Program           Text/Phone/Internet/Social Media

During School           School Sponsored Event      Other

Name of Target(s) 

Name of Aggressive Student(s) 

Name(s) of Witness(es)/Bystander(s) 

Type of Incident

Electronic (select all that apply)
            Text Messages    Website    E-Mail    Facebook    SnapChat    Instagram    Other

Physical (select all that apply)
            Shoved/Pushed    Hit/Kicked/Punched    Inappropriate Touching    Other

Social (select all that apply)
            Excluded    Staring/Leering    Writing/Graffiti    Other

Unlawful (select all that apply)
            Stole/Damaged Possessions   Extortion    Other

Verbal (select all that apply)
            Threatened    Taunting/Ridiculing    Told Lies or False Rumors    Mean Comments     Other


Did anyone get injured? Yes     No
Did you report this incident to law enforcement?Yes     No

Describe the incident(s), including what the alleged offender(s) said or did and the harm:



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Pawnee CUSD 11 810 N. Fourth Street Pawnee, IL  62558

PH: 217-625-2471 Fax: 217-625-2251

This institution is an equal opportunity provider.

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