Bullying Incident Reporting Form

Name of Bully Actor:
Name of Victim Responder:
Name of adult filing report:

Bullying = bully actor perspective + Action + Victim Responder perspective


Bully actor perspective = Desire to hurt +
Superior Power/enjoyment +
Desire for control
Action = Hurtful + Repeated
Victim responder perspective = Vulnerability +
Sense of oppression/unjust treatment


A desire to hurt
Do you think the perpetrator wanted to hurt the targeted person in some way? Yes/No

If Yes, what makes you think so? In what way(s) did the perpetrator want to hurt the other person?

Power Balance
How would you describe the apparent relative power of the bully actor and victim responder? (Consider size, strength, age, number of supporters present)

Add any factors that may have contributed to the imbalance of power. (Consider personality characteristics, popularity, social skill and status)

Evident Enjoyment by the Aggressor
How is the aggressor reacting to the situation? (Consider: feels unconcerned, happy or justified in the taking the actions described above)

Is this child experiencing any remorse?

Is the school aware of any negative events that are happening or may be affecting the child’s life at this time? (This question may be removed if the form is to be used with both sets of parents)

Is there a pattern of this type of behavior for the aggressor?  (Consider if he/she is treating some others in the same way)

An Unjust Use of Power
Were the aggressive actions of the perpetrator to any extent justified? (Consider whether there had been any provocation by the victim responder or whether there was an acceptable use of authority involved)

Why do you see the action as ‘unjust’?


A Hurtful Action
What action took place?  (In describing the action, include possible physical, verbal and indirect actions)

Repetition (typically)
How often has this happened?

Under what conditions has it been happening?


A Sense of Being Oppressed
How is the victim responder reacting to the situation?  (Consider: unconcerned, nonchalant, acting assertively, fighting back, acting angry, frightened, seeming depressed, self-blaming, complaining, or threatening)

How does the victim responder perceive what has happened?  (Consider: did it seem unfair, unexpected/ expected, provoked in some way, or unprovoked, a one time occurrence, likely to recur)

What would this child like to have happen now?

What does this child need in order to feel safe?

Notes on Action Taken Regarding This Incident: