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    

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. :

What School Did The Incident Occur At? :