Report A Bully - Junior High

	“Bullying” happens when someone with more power unfairly hurts someone with less power over and over again. Power may be physical strength, social skill, verbal ability, or another resource. Is it bullying?

Did the bully hurt you physically, mentally, or emotionally?*

		Yes		No
.

Were you hit, pushed, teased, or left out of a group?*

		Yes		No
.

Has this happened more than once?*

		Yes		No
.

Did something happen that made the bully do what he or she did?*

		Yes		No
.

Please fill in all the information you can to help us stop the bully!
.
Please try to give us a name or nickname. Don't worry about the spelling, spell it like it sounds.

		Main Bully's First Name		Main Bully's Last Name
Bully's Name

The MAIN BULLY is a

		Male		Female
.

If there was a second Bully or a person helping the Bully put their name on this line.

		Second Bully's First Name		Second Bully's Last Name
Second Bully's Name

The SECOND BULLY is a

		Male		Female
.

You can use any name including nicknames. If it was you, then put your name.

		Victim's First Name		Victim's Last Name
Victim's Name

The VICTIM is a

		Male		Female
.

	Date of Incident Do the best you can to remember the date and time. You can use the calendar.
	mm/dd/yyyy

	Time of Incident

	Please describe the incident:

	Do you know the MAIN BULLY?
	Do you know the MAIN BULLY? My Friend Not My Friend Other, please specify

	Do you know the SECOND BULLY?
	Do you know the SECOND BULLY? My Friend Not My Friend Other, please specify

	Do you know the VICTIM?
	Do you know the VICTIM? My Friend Not My Friend Me Other, please specify

	Where did the incident happen?

	Please give us the names of WITNESSES or BYSTANDERS who might have seen this happen.

Your information is optional but is helpful to us.

		First Name		Last Name
Your name

		Phone Number		Email Address
.