Bullying Report Form
I have reported this event to my school:
Name of person being allegedly bullied
Name of alleged bully
The alleged bully is a
Location of bullying
Time of incident
I am a
Parent / Guardian
Person being bullied
Type of event
Select all that apply.
Physical -Hitting/kicking/other physical aggression
Verbal -Teasing, name-calling, put-downs, or other behavior that would hurt others’ feelings or make them feel bad.
Emotional/Exclusion -starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends
CyberBullying -Using an electronic medium to engage in any previously mentioned bullying
Description of event
Please be specific (time, date, location)
Did you witness the event?
List other school staff or students who witnessed the event.
Your Name (Optional)
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