Bullying Report Form

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Definition of Bullying: A person is being bullied when he or she is exposed, repeatedly and over time, to negative actions on the part of one or more persons.
Characteristics of Bulling: 1) The behavior is aggressive or malicious. 2) It is repeated and goes on over time. 3) It occurs in an interpersonal relationship which is characterized by a certain imbalance in strength or power.

Name of person being bullied. *

Date bullying occurred (mm/dd/yyyy - example: 01/01/2000) *

Name of bully: *

Your name (optional):

I am a: *

student

staff member

parent/guardian

person being bullied

community member

friend

Required

Type of bullying (select all that apply): *

physical: involves hurting a person’s body or possessions. Examples such as: hitting/kicking/pinching, spitting, tripping/pushing, etc.

verbal: saying mean things. Examples such as: teasing, name-calling, etc.

social/relational: involves hurting someone’s reputation or relationships. Examples such as: leaving someone out on purpose, telling others not to be friends with someone, spreading rumors, etc.

electronic or written communication: bullying that takes place through the use of written messages or using various forms of electronic technology. This includes all forms of Cyber-bullying. Examples such as: mean text messages or emails, rumors sent by email or posted on social networking sites, rumors sent by email or posted on social networking sites, etc.

Required

Description of what happened: *

Did you witness the bullying? *

yes

List names of other students/staff who witnessed the bullying:

Would you like to be contacted about this incident? If so, include name, phone number, email address or any other way you may be contacted.

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This form was created inside of Bartholomew Consolidated School Corporation. Report Abuse

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