Bullying Report Form
Student Report Form
Please check off the boxes that apply to the incident
happened more than once
threatening to cause harm
leaving someone out on purpose
telling others not to be friends with someone
embarrassing someone in public
taking or breaking someone's things
making mean or rude hand gestures
What happened? Describe the bullying.
Who was bullying? Please give full names.
Who was being bullied?
When did the bullying happen?
Where did the bullying happen?
Who was the target of the bullying? If you don't know their name, describe them.
Who else saw the bullying?
Have you told anyone else about the bullying? Who was it?
Did anyone help you?
Write any additional comments here.
Name, homeroom, grade (all optional)
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