PUNIT ELEMENTARY SCHOOL
Punit, Benito Soliven, Isabela
BULLYING INCIDENT REPORT FORM
Guidance Office
Date of Time of Incident Repeat Infraction
Incident (Yes/No)
Location of the Incident (Check all that apply)
Corridor Classroom Gym School Ground
Canteen Comfort Room Social Media Other
Name of Victim Name of Student(s) bullying Name(s) of witness/bystander
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Types of Bullying (with description of the incident
Physical Relational
Verbal Cyberbullying
Bullying Behaviors (Check all that apply)
Shoved/Pushed Hit/kicked/punched Threatened Ridiculing Stole/damaged possession
Excluded Writing Told lies/false rumors Staring/leering Intimidation
Extortion Demeaning comments Inappropriate touching Others
Cyberbullying using: Text messages Posting of pictures Social Media
Reported to the school by: (check all those that apply)
Teacher Student Victim Bystander
Parent Anonymous Guard on Duty Other
Action Taken:
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Recommendation:
______________________________________________________________________________________________
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Today’s Date __________________ Reported by: ____________________ Signature ______________
BULLYING INCIDENT FOLLOW UP FORM
Guidance Office
Today’s Date ______________________ Time: ______________________________
Conducted by: ______________________________________
People Present
School Head Student Guidance Counselor Class Adviser Subject Teacher
Child Protection
Council Parent Social Worker Prefect of Discipline Others:
According to the student, situation is:
______ Better _____ Worse _____ No difference
Comments:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Additional Action:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
CASE STATUS: __________________________ (Pending/ Resolved)
BULLYING INCIDENT FOLLOW UP FORM
Guidance Office
Today’s Date ______________________ Time: ______________________________
Conducted by: ______________________________________
People Present
School Head Student Guidance Counselor Class Adviser Subject Teacher
Child Protection
Council Parent Social Worker Prefect of Discipline Others:
According to the student, situation is:
______ Better _____ Worse _____ No difference
Comments:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Additional Action:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
CASE STATUS: __________________________ (Pending/ Resolved)
