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CHS Bullying Incident Report
*Document MUST be completed within 2 school days of alleged bullying incident.
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Email
*
Your email
Date:
MM
/
DD
/
YYYY
Reported by:
Your answer
Student Name:
Your answer
Alleged Perpetrator(s):
Your answer
Nature of conduct:
Physical
Verbal threats
Sexual
Other:
Summary of Incident:
Your answer
Date event occurred:
MM
/
DD
/
YYYY
Time event occurred:
Time
:
AM
PM
Location:
Your answer
Any discipline applied at event:
Yes
No
Clear selection
Discipline applied:
Your answer
Support provided to victim
Yes
No
Clear selection
Support provided:
Your answer
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