MOUNT CARMEL AREA HIGH SCHOOL
BPCC INCIDENT REPORT FORM
DATE OF INCIDENT:_________________________________ INCIDENT #________
STUDENT’S NAME (Person who bullied):__________________________________________
GRADE: ______ TEACHER:______________________________________________
TEACHER/STAFF MEMBER REPORTING THE INCIDENT: _____________________
WHERE INCIDENT TOOK PLACE:_________________________________________
VICTIM(S) NAME AND GRADE:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
WITNESS (ES) NAME AND GRADE:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
BULLYING BEHAVIOR DISPLAYED
PHYSICAL VERBAL EMOTIONAL/SOCIAL CYBER
HITTING,KICKING TEASING LEAVING PEOPLE E-MAIL
PINCHING, TRIPPING NAME CALLING OUT AOL/MY SPACE,
KICKING, PUSHING MAKING OFFENSIVE SPREADING ETC…
SCRATCHING, REMARKS RUMORS CELL PHONE
SPITTING MAKING EXCLUDING OTHER
DAMAGING/STEALING DISCRIMINATORY SOMEONE
PROPERTY REMARKS IGNORING SOMEONE
THROWING OBJECTS INSULTING SOMEONE MAKING FUN OF
AT SOMEONE THREATENING SOMEONE
HIDING/TAKING SOMEONE STOPPING PEOPLE
BELONGINNGS REPEATED TEASING FROM BEFREINDING
OTHER INTIIMIDATING SOMEONE
SOMEONE OTHER
OTHER
EXPLAIN INCIDENT:_____________________________________________________
______________________________________________________________________
______________________________________________________________________
ACTION TAKEN AFTER INCIDENT:_______________________________________
______________________________________________________________________
______________________________________________________________________
FOLLOW UP
WITH PERSON WHO BULLIED: YES NO
IF YES, DATE OF FOLLOW UP: _________________
FOLLOW UP DONE BY: _______________________________________
WITH VICTIM(S): YES NO
IF YES DATE OF FOLLOW UP: _________________
FOLLOW UP DONE BY: _______________________________________
ADMINSTRATIVE RESPONSE:
Spoke with Student Date: _________
Spoke with Parents Date: _________
In-School Suspension Date: _________
Out-of-School Suspension Date: _________
