Report Bullying

Your Name and Grade :

Today's Date :

I am a... :
  Victim       Witness       Staff Member       Parent/Guardian       Community Member       Other    

Name of Alleged Bully :

When did the event occur? :

Where did the event occur? :
         Classroom       Lunch Room       Locker Room       Bus       Bus Stop       Gym       Other    

At which school did the event occur? :

Describe the event accurately and specifically. Write down exactly what was said and thoroughly describe what physical actions (if any) were taken. :

Has the bully done this to the same victim on other occasions? :
  Yes       No       I don't know    

Please list the names and grades of others who witnessed the incident. :