Bully Report You Name (optional) First Name Last Name Relationship to Victim (optional) Parent Grandparent Guardian Friend Other Name of Victim * First Name Last Name Date(s) of Incident * MM DD YYYY Where did this happen? * On school property At a school sponsored activity or event of school property Online What happened? Choose all that apply. * Teasing Taunting Made fun of Shoving or Pushing Hitting or Kicking Name calling Getting someone in trouble Gossip and rumors being spread Being left out on purpose Online bullying (social media, e-mail, text, etc.) Describe what happened (the most recent incident). * Have you taken any actions to resolve his/her behavior or the situation? (Please explain) * How has this incident affected you? * Is there anyone who witnessed this behavior? * Yes No If yes, then who? Have you reported prior problems with this student to a teacher or other staff member? * Yes No If yes, then who? What would you like me to do to help? * Thank you!
