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Bullying Reporting Form
Bullying is a form of violence that involves one or more individuals using power to chronically control and/or intentionally demean, embarrass, or harm another individual or group (California Department of Education, 2003). Bullying may be physical (hitting, kicking, spitting, destroying property), verbal (taunting, name calling, insults, threatening), or emotional (spreading rumors, excluding from activities, humiliating, or intimidating). Bullying may occur face to face or through the internet, cell phones or other electronic means (cyber-bullying).
Name of Reporter/Person Reporting Bullying
Phone or email contact of the Reporter/Person completing the report
I am a
Specific details of the incident, including names involved, grades, date, & location.
Have you reported this to anyone else?
Please list the names of witnesses.
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This form was created inside of Inland Leaders Charter School.