Bully Report Form
This is not required. You are allowed to remain anonymous.
Date of Incident
When did it happen?
Location of Incident
Where did it happen?
Person who was bullied
Were you the victim or was it some one else? Please enter first and last name.
Name of Student who is bullying
Enter first and last name
Has this person bullied you more than 2 - 3 times in the past 2 weeks?
Type of Bullying
Choose all that apply
Physical (repeated pushing, shoving, pulling hair, etc.)
Emotional (repeated name calling, teasing, etc.)
Social (repeated rumors, gossiping, looks, exclusion, etc.)
Cyber (repeated facebook, texting, instagram, snap chat, twitter, etc)
Did this happen during school hours or during a school sponsored event?
During a school event
Outside of school
Did a school staff member witness?
Please list adult name.
TIPS and NEXT STEPS…….. 1. Ask the bully to stop, Ignore, avoid, stand by a teacher, etc. 2. DON’T retaliate. It only enables the bully and gets you in trouble while the bully is not. 3. Realize students bully because they are being bullied, they are unhappy, they feel a lack of power, they need your attention. BE STRONG. You will be OK!
Also, the best way we can all stop bullying is for students to stand up for each other. Be a defender! Please ENTER TODAY'S DATE BELOW
Describe what happened....
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