Bully Report Form
Your Name
This is not required. You are allowed to remain anonymous.
Your answer
Date of Incident *
When did it happen?
Your answer
Location of Incident *
Where did it happen?
Your answer
Person who was bullied *
Were you the victim or was it some one else? Please enter first and last name.
Your answer
Name of Student who is bullying *
Enter first and last name
Your answer
Has this person bullied you more than 2 - 3 times in the past 2 weeks?
Type of Bullying *
Choose all that apply
Did this happen during school hours or during a school sponsored event?
Did a school staff member witness?
Please list adult name.
Your answer
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
Incident Details
Describe what happened....
Your answer
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