Confidential BULLY REPORT
My Name:
I am a:
bullied student
bystander
supervising adult
transcribing for someone else
Other
I am being bullied and this is what I have tried to do:
I did nothing
Told them to stop
Walked away
Asked someone for help
Talked to someone about it
Tried to ignore it
Other
The person or persons bullying me:
Date of first contact:
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Month
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Day
Year
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:
Hour
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10
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30
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50
Minutes
AM
PM
AM/PM Option
Description of Bullying behavior:
Comments:
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