Bullying Report
*Remember* Bullying is REPETITIVE and involves an IMBALANCE of power
* Required
BE an UPSTANDER!
Date
*
MM
/
DD
/
YYYY
Name (leave blank to be anonymous)
Your answer
I am...
*
A student- elementary
An MYP Scholar
Parent or Guardian
Staff member
Other:
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?
*
one time
2-5 times
more than 5 times
Please describe one or more incidents. Please state facts only.
*
Your answer
Did you tell an adult?
*
Yes
No
If yes, who did you report to and what happened?
Your answer
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