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Madison Metropolitan School District

Workplace Bullying Report Form

Important definitions to consider:

  • Workplace bullying is the repeated, unreasonable actions of an individual (or group) directed toward a peer, co-worker or employee that is intended to intimidate and creates a risk to the health or safety of the target.
  • A target is an individual subjected to workplace bullying by his/her peers, co-workers and/or supervisor.


Name of person reportingrequired
First Name
Last Name
Name of targetrequired(if different from person reporting)
First Name
Last Name
(if different from person reporting)
Name of alleged bullyrequired
First Name
Last Name
Date(s) of alleged incident(s)required
Time(s) of alleged incident(s)required
Location(s) of alleged incident(s)required
Description of alleged incident(s)required
Factors that should be considered in response to alleged incident(s)required