Student Bullying Report
Bullying is negative acts that is done on purpose and involves an imbalance of power. Bullying is not a one time action, but it is repeated over time.
First and last name of victim (who is getting bullied)
Grade of victim
First and last name of the alleged bully (who is alleged offender)
Grade of alleged bully
not a student
Name of any witnesses (who saw this happen to you)
Who is reporting this information? (Who is completing this form)
Dates of incidents (What dates did it happen?)
Where did the incident occur (check all that apply)
in the bathroom
at school event
Which statement(s) best describe what happened? (check all that apply)
Bullying, harassment, or intimidation involving physical aggression
Teasing or name-calling
threatening and/or verbal intimidation
Rude or threatening gestures
Spreading harmful rumors/ gossip
Cyber bullying (ex. Facebook, Twitter, Instagram, Vine, YouTube)
Electronic Communication (ex. GMail, text messages, KiK, Snapchat, online chats)
Property damage or stolen property
Please provide details about the situation
How many times has the incident occurred or the alleged bully done something to the victim?
Have you told anyone about the bullying? (check all that apply)
Other school staff member
I haven't told anyone
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This form was created inside of Union County Public Schools.