Person Reporting Bullying (required)
First Name

Last Name (required)

Email Address (required)

What is today's date?

When did the bullying happen?

Who do you think was bullied? (First Name and Last Name)

Who is this person's teacher?

What grade?

Who do you think was bullying?

What grade?

Type of Bullying (check all that apply)
Called mean namesExcluded (left out)Took or damaged somethingThreatenedHit, kicked, punchedTold lies/spread rumorsCyber-bullying (online/eMail/text, etc.)Racial/offensive Comments (talking)

Where did the bullying happen? (check all that apply)
HallwayCafeteriaOn the BusBus StopClassroomPlaygroundBathroomGoing to/from schoolOnline/eMail/text

Is this the first time that this has happened?

Have you filed a Student Bullying Report before?

Who has been told about the bullying or saw what happened?
TeacherPrincipalFriendParent/GuardianAssistant PrincipalStudentsCounselorNobody Yet

Any other information that you would like to share?