Bully Reporting Form
Definition of Bullying: an overt, unwanted, repeated act or gesture, including written or verbal communications or images transmitted in any manner, physical acts, or any other behaviors that are committed by a student or group of students against another student with the intent to harass, ridicule, humiliate, intimidate, or harm the other targeted student and create for the targeted student an objectively hostile school environment. Bullying is NOT peer conflict, horseplay, or fighting. Bullying is considered to be a form of abuse. Mutual conflict where both parties participate equally is not considered bullying.

This form can be filled out by a student or with the help of a parent.

Name of person reporting Bullying
The name of the reporter will be protected and is necessary for any follow up questions and/or clarifications. Anonymous Reports will not be acted upon.
Your answer
Date Bullying Occurred
MM
/
DD
/
YYYY
Grade and/or classroom Teacher of the person being bullied.
Provide whatever information you can.
Your answer
Who do you think was doing the bullying?
Provide whatever information you can.
Your answer
When did the bullying occur?
Check all that apply.
Type of Bullying
Check all that apply
Where did the bullying happen?
Check all that apply
Is this the first time it has occurred?
Have you filed a bullying report before?
Who has been told about the incident or saw what happened?
Check all that apply
Other Information that you would like to share:
Your answer
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