Directions for completing form: Print out this page. Complete all sections an place report in an envelope. Address to appropriate school staff person and mail or put in staff person’s mail slot at school

Bully Report Form

What happened? (what you saw, who did it and who it was done to)

Where It happened. (what hallway, what bus, what classroom, etc.)

Date and time it occurred (bus ride to or from school, what period)

If this report is not anonymous, complete the following:

Name of Person Making Report:__________________________________

Signature and Date:____________________________________________

Please investigate the above bullying report. It is strongly recommended not to interview the bullying victim together with the student who has allegedly bullied him or her. If the report contains too little information to begin a structured intervention, it is recommended to increase staff presence and monitoring in the problem area indicated. Please visit www.Bullystoppers.com for information and tips.