Have you reported this incident to anyone in authority?* Examples: teacher, principal, staff member at a school
	Yes    No

	If you answered yes above, when and to whom did you report the incident?* Enter NA below if you have not reported the incident.

	Name of person being bullied:* (please include first and last if possible)

	Location of incident(s):* Select at least 1.
	at school    on bus    athletic event    Other:

	Name of alleged bully:*

	Date(s) of alleged incident(s):*

	The alleged bully is a:* Select at least 1.
	student    school employee    Other:

	I am a: (optional)
	student    school employee    parent/guardian    person being bullied    concerned citizen    friend    Other:

	Your name: (optional)

	Description of event:* (Please be as specific as possible - location, date, details, etc.)

	Did you witness the event?*
	Yes    No

	If you did not witness the event, how were you made aware of it?

	Please list other staff/students/parents who may have witnessed the event:

	Additional Comments: