Bully Statement
Submit the answers to this form as clearly as possible. Mrs. Jones or Mr. C. will follow up with you confidentially as soon as we can.
What is your first and last name?
Your answer
Who is your homeroom teacher?
What is the name of the student who is bullying you?
Your answer
Where and when did the incident happen?
Your answer
Describe what happened.
Your answer
Did anyone witness the incident? If so, who?
Your answer
Who are your friends at school?
Your answer
Who are people that you find it hard to get along with?
Your answer
Submit
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