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

________________________ ________________________ ______________________
________________________ ________________________ ______________________
________________________ ________________________ ______________________

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:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

Recommendation:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

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)