Name of Victim
Name of Bully
Reporters Name
School of Incident High School Middle School Elementary School
Date of Incident
I am a StudentBully VictimParent/GuardianStaff MemberCommunity MemberFriend
Type of Bullying 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- Using an electronic medium (including but not limited to: texts, e-mails, phone messages, facebook, etc.) to engage in any previously mentioned "bullying".
Decription of Events
Did you witness YesNo
Please list any witnesses
Email of Reporter