Report a Bully
Report a Bully

1. Please fill in all the information you can to help us stop the bully!

  Main Bully's First Name            

  Main Bully's Last Name              

  Second Bully's First Name        

  Second Bully's Last Name         

  Victim's First Name                  

  Victim's Last Name                 

  Date and Time of Incident         

 

2. Tell us your relationship with these people 

Main Bully                                 

Second Bully                             

Victim                                       

Location                                    

Witnesses/By-Standers              

Date/Time of Incident                  

 

3. Tell us your relationship with these people

Main Bully               

Second Bully           

Victim                     

 

4. Where did the incident happen?

 

5. Please give us the names of witnesses or bystanders who might also have seen this happen beside you.

 

6. Tell us what the bully did to the victim

 

7. Other information  that you might help us such as race gender and grade level of the involved

 

8. Your information is optional but appreciated WE PROMISE TO PROTECT YOU

Your First and Last Name:       

Phone Number:                       

Email Address:                       

Grade:                                    

ID Number:                              



Security Measure