Anti-Bullying Task Force

Bully Incident Report

If you have experienced or witnessed an incident of bullying, discrimination and/or harassment at The University of Toledo please use this form to let us know. If you would prefer to speak with someone immediately, contact Lisa Kovach - 419.530.2048 or Jeff Newton - 419.530.4484

Date the incident took place:

What time did this happen:

Type of bullying witnessed:

Physical: Intentional harm to another's body (e.g., hitting, kicking, punching)
Verbal: Repetitively making negative verbal statements or insults to another individual (e.g., teasing, name calling)
Relational: Behavior aimed at hurting someone's relationships with others (e.g., gossip, ostracizing someone)
Cyber: The use of electronic means to inflict harm on another individual (e.g., nasty text messages, IMs, Facebook posts or comments)

Please provide as much detail as possible as to what occurred:

Where did the incident take place?

On Campus.

Off Campus, UT-sponsored event.

Off Campus.

Where at on-campus/off-campus?

Please list the first and last name of person(s) gettiing bullied and any contact information. If names are unknown, please include any known identifying information.

Please list the first and last name of person(s) bullying and any contact information. If names are unknown, please include any known indentifying information.

Name and contact information of Person Reporting:


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Last Updated: 6/26/15