Confidential Bully Report
Optional Contact Information
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I have reported this event to my school:
Name of person allegedly being bullied:
First and Last Name
Name of alleged bully:
I am a:
Person being bullied
Please describe the events in detail.
Was this a one time event?
Did you witness the event?
Type of event:
Please select all that apply
Physical - Hitting/Kicking/Other physical aggression
Verbal - Teasing/Name Calling/Put Downs
Emotional - Exclusion/Starting Rumors/ Telling others not to be friends with someone
Cyber Bullying - Using an electronic medium to engage in an previously mentioned bullying
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