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Bullying Witness Statement Template

This report MUST be completed when there is a witness to an incident of alleged bullying (for the

purpose of this form,

bullying encompasses bullying, harassment, and discrimination.) One form

must be completed for each witness. All

witness statements that relate to one incident should be

attached to the Bullying Complaint Report Form.

WITNESS NAME (last, first)

WITNESS TITLE

(ex. Parent, Student, or

Teacher)

INTERVIEW

DATE

VICTIM NAME (last, first)

ACCUSED NAME (last, first)

SCHOOL SITE (where incident occurred)

SCHOOL TELEPHONE

PRINCIPAL

INCIDENT DATE

Describe the location where the incident took place:

Description of incident witnessed

List any other witness names and grade

List evidence of bullying (i.e. letters, photos, etc. – attach evidence if possible):

I agree that all of the information on this form is accurate and true to the best of my

knowledge.

Signature of witness Date

Name of person receiving Bullying Witness Form Date Title/School

Witness Statement Template Download

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