Anonymous Bully Box
This form allows students to anonymously report possible incidences of bullying. Please answer all questions to the best of your ability.
Does what happened fit all 3 parts of the definition of bullying?
(Respond to the statements below)
This has happened more than once. *
One student has power over the other student. (Example: Physical power, popularity, or access to embarrassing information) *
The person chooses to hurt another person on purpose (physically or verbally). *
Name of Person being bullied *
Your answer
Your Name
Your answer
Name of Accused Bully
Your answer
Location of incident
Your answer
Date and Time of Incident
Your answer
Describe what happened in as much detail as possible *
Your answer
Have you reported this to an adult? If so, who?
Your answer
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