* 1. Person(s) Reporting: (Please note that without providing your contact information, it may be difficult to pursue this report).

* 2. The Person Submitting This Report Is:

  Reporter
Student
Student Witness
Parent/Guardian
School Personnel
Other

* 3. Target of Bullying - Who was being bullied?

* 4. Witnesses - Who saw what happened?

* 5. Type of Behavior - What did they do?

  Check All That Apply
Cyber / Electronic Media (Internet website postings, chat rooms, videos)
Social (excluding, intimidation, telling lies/rumors, taunting)
Physical (hitting, pushing, stealing, stalking)
Verbal (calling names, threatening, demeaning comments)

* 6. Response - What did you do (if anything) in response to the bully's behavior?

* 7. Please Specify the Location(s) - Where did it happen?

  Check All That Apply
Classroom
Locker Room
Hallway
Gymnasium
Lunchroom
Restroom
Recess
On Bus / At Bus Stop
Text/Phone/Internet/Social Media

* 8. Is this the FIRST time that an incident has occurred?

 
Yes
No

* 9. Date and Time of Incident(s) - When did it happen?

Incident #1 Date and Time:
/
/
:
Incident #2 Date and Time:
/
/
:
Incident #3 Date and Time
/
/
:

* 10. Has this situation been reported to an adult?

 
Yes
No

* 11. Describe, in as much detail as possible, the specifics of this bullying incident.

T