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
Please enter all of the characters you see from left to right.