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S-185-A Bullying Incident Report Form
New Bloomfield R-III School District

Your Name (Person Completing Form): 


Your Role: (Select One) 


Your Telephone Number: 


Your Email Address: 


Victim's First Name:              Victim's Last Name: 


Victim's Student ID:                    Victim's School: 


Name of person(s) you believe committed bullying:


State the nature of your report. Please describe the action(s)/incident(s) you believe may be in violation of the District's anti-bullying policy as clearly as possible, including such things as what physical force or contact, if any, was used and any verbal statements that were made (i.e. threats, requests, demands, etc.). Definitions of 'bullying', 'hazing', and 'cyberbullying' under District Policy can be found by clicking https://egs.edcounsel.law/new-bloomfield-r-iii-school-district-policies/



If others are affected by this possible violation, please also give their names and/ or positions: 


Date of alleged incident(s): 


Where did the incident(s) occur?


Please list any witnesses who were present, or others who may have information regarding the incident(s): 


Please provide any other information relevant to this incident of bullying.