Bully Reporting Form 

Click "Submit" when finished to send

Name of person being bullied:        
           
Date: 

Name of bully:   

Your Name (optional):   

I am a:

 Type of Bullying (Select all that apply):

    Physical-Hitting/ kicking /other physical aggression

    Verbal:  Teasing, name-calling, put-downs, or other behavior that would hurt others’ feelings or make them feel bad.

    Emotional/Exclusion-starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends

    Cyber Bullying:  Using an electronic medium to engage in any previously mentioned 'bullying'

Description of events:  (Please be specific-Location/Date/Time):

Did you witness the bullying?

    yes

    no

List other students/staff who witnessed the bullying…