Bullying Report Form
Have you reported this incident to anyone in authority?
This would include a teacher, principal, or staff member at school.
Name of the person allegedly being bullied.
Please put the first name and the last name if known.
Location of the alleged incident.
On a Bus
Date of the alleged incident.
Name of alleged bully is a:
Your Name (optional)
First name and last name.
I am a
Person Being Bullied
Please check all that apply.
Physical: Hitting, kicking, or other physical aggression
Verbal: Teasing, name-calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad
Exclusion: Starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends
CyberBullying: Using a computer, cell phone, or other electronic devices to engage in any previously mentioned bullying.
Description of the event.
Please be as specific as possible and include location, date, and time of the alleged incidents.
Did you witness the event?
Please list other students/staff who witnessed the event.
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