Fairfield Junior High School

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District	Campus
	CAMPUS

Please complete this form to the best of your knowledge so we can assist you.
This information will be kept confidential with your campus administrator and/or superintendent.

Please Fill Out The Incident Report Below

Date of Incident:

Date of Report:

Who was the person(s) engaged in incident?

Grade of person(s) who engaged in bullying?

Grade of person who was being bullied?

What type of bullying?

Physical

Emotional/Social

Damage to Property

Online

Other

Other location details: (Please explain the specific location details such as which hallway, where on the Internet, what restroom, etc)

Describe what happened with as many details as possible.

Person reporting the incident:(OPTIONAL). Please use your full name.

May we contact you for more information on this incident?

Yes

Thank you for reporting this incident. We appreciate your concern. When you click "Submit Form" this will be sent to the campus administrator.

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