Bullying Report Form
Email *
Date reported *
MM
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DD
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YYYY
Victim's name: *
Name of person reporting
Your name and information will be kept confidential.  Someone from the counseling department may contact you if more information is needed.  You may choose to remain anonymous if you wish.
Relationship of person reporting to victim:
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Accused bully name(s) OR a description of bully (if name is unknown) *
Location of incident
Date and time of incident
MM
/
DD
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YYYY
Time
:
Type of harassment/bullying (description of each provided on bully homepage)
Describe what happened in as much detail as possible: *
Is this the first time this has occurred? *
Is there any evidence associated with this incident (social media, text, voicemail, marks, etc)?  Please save evidence.
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Name of any witness(es)
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