Tupelo Public Schools

Thsi report can be completed when there is a witness to an incident of alleged bullying. One form must be completed for each witness. All witness statements that relate to one incident should be submitted as soon as possible after the Bulying/Harassment Incident Report Form is submitted.

Please Fill Out The Bullying/Harassment Incident Witness Form (Online Form) Below

Reporting Person Information

Name:

Telephone:

E-Mail:

Date of testimony, interview:

School Site where incident took place:

Incident Date:

Incident Time:

Student Affected:

Students(s) Initiating Bullying/Harassment:

Description of incident witnessed:

Please describe how you responded to the incident:

I agree that all of the information is accurate and true to the best of my knowledge.

Your Name: (this serves as your electronic signature)

Date:

Email a copy to

optional

Required Fields