TJH Bullying Incident Report

Please read the following to decide if your situation is considered bullying.

Bullying- Bullying is unwanted, aggressive behavior among students that involves a real or perceived power imbalance. The behavior can be isolated or repeated over time.

The repeated acts or gestures can include: 

  • verbal or written communications transmitted,
  • physical acts committed, or
  • any other behaviors committed

by a student or group of students against another student with the intent to harass, ridicule, humiliate, intimidate, or harm the student lacking power.

Peer Conflict-Peer conflict differs from bullying because involved parties are mutually agreeing through demonstrated actions that they are in conflict with each other.  Bullying is one-sided.  When people say hurtful things to each other or refuse to speak to each other, that is considered peer conflict. Also, if a person is spreading rumors about you and you have ALSO been spreading rumors or talking bad about them, that is considered conflict.

If you have decided that your situation is bullying then please fill out this form.  If you think you have a situation involving Peer Conflict, please stop by the main office to make an appointment with a school administrator and/or guidance counselor.


Date (Example:08/18/2015)                                                              

Name of Student Making the Report

Please include first name, last name, and middle initial.  School officials will take every measure possilbe to keep your name confidential.  Reporting includes responsibility.  Individuals making reports must also assume a level of confidentiality and follow steps recommended by school personnel.

Important Note:  Due to student privacy and confidentiality laws,  school personnel are not allowed to release the outcomes of an report, incident, investigation, or consequence.

Team Name


Name of the Potential Bully/Bullies

Please report the name of the potential bully and/or bullies. Please include details such as first name, last name, grade level, team, class,  etc. if the name of the individual is unknown.

 How often is this happening? 

*Once Twice More than twice I have heard about this.  


Where is this happening?

 Classroom   Gym/Locker Room   Lunchroom   Hall    Bus                   

To/From School Bus Stop  


What is happening?

Teasing Hitting/Kicking Cyberbullying Name calling *Shove/Push

Gossip/Rumors Disrespect of Property



Security Measure