Bully Busters Report Form
We have developed a school wide program to bring awareness and prevention of bullying behaviors. There is a difference between bullying and being mean. Bullying is when there is an IMBALANCE OF POWER, the behavior is INTENTIONALLY HURTFUL, and REPEATED (3 or more times) over time.

There are 4 main types of bullying: Physical (using actions), Verbal (using words), Social (using other groups), and Cyber (using technology). Some ways of bullying are: name calling, writing nasty things about others, leaving someone out of activities, threatening, intimidation, bossing others, or using websites to bully.

Please let us know about any bullying that may be occurring in our school. We want to make sure our students feel safe. Your report will be investigated and promptly dealt with. If this is an emergency or needs immediate attention please contact your student's Principal or Counselor directly.

I am a:
Your name
(optional)
Your answer
Your Contact Information (phone or email address)
(optional)
Your answer
Name & Grade of student(s) being bullied:
(Last Name, First Name), Grade
Your answer
Name of other students involved or who have witnessed the situation:
(include the First & Last Name of anyone showing bullying behaviors or witnessing the behaviors)
Your answer
What type of bullying are you reporting?
(see above for definitions)
Date bullying situation happened:
MM
/
DD
/
YYYY
Where did the incident occur (check all that apply)
Required
Please describe what happened.
Your answer
To your knowledge, has this type of incident happened with this student before?
To your knowledge, has this been reported before?
Submit
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