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
:
AM
PM
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.