Rosebud-LottIndependent School District

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2018 - 2019 High School Graduation will be on Friday, May 24, at 8:00 p.m.

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HS BULLYING INCIDENT REPORT FORM

Repeat Infraction?*
Location of Incident (check all that apply)*

Name of Victim(s)

Name of Student(s) Bullying

Name(s) of Witnesses/Bystanders

Type of Bullying*
Bullying Behaviors (check all that apply)*
Cyber-Bullying used
Result in Injury
Reported to School Nurse?
Reported to Police?
Reported to School by (check all that apply)
Physical Evidence?
Confirmation Email