Bully Reporting Form
Name of person being bullied:
First Name
Last Name
Grade of person being bullied:
Please select grade level
6th
7th
8th
9th
10th
11th
12th
Name of person violating bullying policy:
First Name
Last Name
Grade of person violating bullying policy:
Please select grade level
6th
7th
8th
9th
10th
11th
12th
Your Name:
First Name
Last Name
I am a:
Select Reporter Category
Student
Staff Member
Parent/Guardian
Person being bullied
Community Member
Friend
Type of Bullying (Select all that apply):
Physical:
Hitting/ kicking /other physical aggression
Emotional/Exclusion:
starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends
Cyber Bullying:
Using an electronic medium to engage in any previously mentioned 'bullying'
Verbal:
Teasing, name-calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad
Description of events: (Please be specific-Location/Date/Time):
I witnessed the bullying
List other students/staff who witnessed the bullying...
First Name
Last Name
First Name
Last Name
First Name
Last Name
First Name
Last Name
First Name
Last Name