Bullying Report
*Remember* Bullying is REPETITIVE and involves an IMBALANCE of power
BE an UPSTANDER!
Date *
MM
/
DD
/
YYYY
Name (leave blank to be anonymous)
Your answer
I am... *
Who are you standing up for? *
Your answer
Who is doing the bullying? (first, last, and grade) *
Your answer
How many time has this occurred? *
Please describe one or more incidents. Please state facts only. *
Your answer
Did you tell an adult? *
If yes, who did you report to and what happened?
Your answer
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