Conflict Report

This form is to be completed by the bullying target, witness, or person with information about an

incident of bullying or school violence. It will be electronically submitted to the building principal

and assistant principal. Items marked with an astrick are required.

Name (first and last)*

Answer Required

Date*

Answer Required

If you answered "other" above, please identify yourself here:

Answer Required

Are you the target of the bullying or school violence that you are reporting?*

Answer Required

Yes

Date pf incident:*

Answer Required

Time of incident:

Answer Required

Person(s) being reported as target(s) of bullying or school violence:*

Please list each person's first and last name and indicate if they are a student or staff.

Answer Required

Person(s) being reported as aggressor(s) engaged in bullying or school violence:*

Please list each person's first and last name and indicate if they are a student or staff.

Answer Required

Person(s) who witnessed the bullying or school violence:

Please list each person's first and last name and indicate if they are a student or staff.

Answer Required

If you answered "other" above, please identify a characteristic not listed:

Answer Required

Student(s) were targeted for bullying in the following way(s):*

(check all that apply)

Answer Required

Electronic devices (e.g. internet, social media platforms, text, email, cyberbullying, etc.)

Written communication (e.g. handwritten notes, other written documents, email, etc.)

Physical act or conduct (e.g. pushing, hitting, destruction of property, stalking, etc.)

Verbal act or conduct (e.g. rumors, lies, namecalling, using derogatory slurs, etc.)

Social (e.g. purposeful exclusion, causing psychological harm, etc.)

Items depicting implied hatred or prejudice were worn, possessed or displayed

Other (complete next section)

If you answered "other" above, please identify a way not listed:

Answer Required

If you answered "other" above, please identify a location not listed:

Answer Required

Please tell us about the incident in your own words. Use as much detail as possible.*

Answer Required

Byron Middle School