Bully Reporting Form
This is a place for you to submit a concern or problem with a bully. It can be filled out with your name or not a name of who is submitting this form. Please remember that it is very important to give as much detail as possible when reporting. Also, giving your name will help us to get more details. No one will know who reported except for school administrator.
Name of person being bullied: First & Last
Name of bully:
I am a:
Person being bullied
Friend of person being bullied
Type of Bullying (Select all that apply):
Physical-Hitting/ kicking /other physical aggression
Verbal: Teasing, name-calling, put-downs, or other behavior that would hurt others’ feelings or make them feel bad.
Emotional/Exclusion-starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends
Cyber Bullying: Using an electronic medium to engage in any previously mentioned 'bullying'
Description of events: (Please be specific-Location/Date/Time):
Did you witness the bullying?
List other students/staff who witnessed the bullying…
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