Hodge Elementary School - Bullying Allegation Form
Name of Person making the report: ___________________________ Date of Report: __________
Parent/Guardian of: _____________________________________ grade ______ID#____________
When did this happen: (Date/Time of day) __________________________________________
___ Single Incident ___ Series of Incidents ___ Not sure
Are there immediate safety needs? ___Yes ___No If yes, please describe: _______________
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Name of person suspected of bullying if known and grade/teacher: _________________________ ________________________________________________________________________________
Bystanders/Witnesses: _____________________________________________________________
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Where did the incident occur?
___ Restroom ___School Event ___ In transit to/from
___Classroom ___ Extended Day School
___ Hallway ___ Parking Lot ___ Computer Lab
___ Dressing/Locker room ___ Cafeteria ___ Internet
___ Bus ___ Auditorium ___ Cell Phone
___ Bus Stop ___ Lecture Hall ___ Other (add below)
___ Playground/Athletic field _________________________
Description of the bullying behaviors: ________________________________________________
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(attach additional paper if needed)
Specific concerns: ( check all that apply)
Physical ___ Emotional ___ Relational ___ Cyber Bullying ___ Bus Issues ___
Fear of Retaliation___ Damaged Clothing or Property ___ Other ______________________
Who was informed? Teacher(s) __________________________________________________
Administrator(s) _________________________________________________________________
Student Resource Officer ___________________________________________________________
Counselor(s) _____________________________________________________________________
Other ____________________________________________________________________
