Bully Reporting Form
Name of person being bullied:
First NameLast Name
Grade of person being bullied:
Name of person violating bullying policy:
First NameLast Name
Grade of person violating bullying policy:
Your Name:
First NameLast Name
I am a:
 
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 NameLast Name
First NameLast Name
First NameLast Name
First NameLast Name
First NameLast Name
Please enter all of the characters you see from left to right.