BULLYING INCIDENT REPORT

First Name

Last Name

Email Address

Address

City

State

Zipcode

Incident Information

When did the incident occur?

Where did the incident occur?

Your Role:

Additional Information

Please include any information about how you were involved or know of this incident.

Name of person being bullied, harassed, harmed or intimidated.

Name of the offender who was bullying, harassing, causing harm or intimidating.

Describe the incident giving as much detail as possible.

2016 Madison Avenue
Granite City, IL 62040
(618) 876-2383
Fax: (618) 876-4952