Report A Bully
Please fill in all the information you can to help us ! Please try to give us names or nicknames. Don’t worry about the spelling, spell it like it sounds. Do the best you can to remember the date and time. Be sure to identify the school you are from, so we can direct your information effectively. Remember that you must answer all questions marked with a red asterisk * before you will be able to submit this report. If there is an immediate concern or you believe bullying is occurring now, go to the office/ school employee and report it immediately.
First and last Name
(Optional)
Your answer
Your grade/role:  *
*  Please select an option 
Today's Date *
MM
/
DD
/
YYYY
Campus incident occurred  *
*  Please select an option 
Please indicate where this incident happened:  
Your answer
What is the first and last name(s) or other information of the person who you believe is causing the problem? Describe what the person(s) looks like, their age, grade, clothes they were wearing, etc:  *
*Name and description of the bully.
Your answer
What is the first and last name(s) of the victim(s) or other information that will help us identify them, such as grade level, age, what the person(s) looks like, what the person(s) was wearing, etc:  *
Your answer
What day did this occur?
Please use the following format Date: mm/dd/yyyy
MM
/
DD
/
YYYY
What time did this occur?
Time
:
What happened? *
(Be as detailed as possible): *
Your answer
Have you told any teacher, school administrator, parent or other adult about this incident * *
If you answered yes, please indicate who you spoke with and when.
Your answer
Your phone number and/or e-mail address
(Optional)
Your answer
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