Report A Bully - High School

	“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.
	Main Bully's First Name   Main Bully's Last Name Bully's Name

	The MAIN BULLY is a
	Male   Female .

	The MAIN BULLY is in
	Kinder - 1st   2nd - 3rd   4th - 5th   6th - 7th   8th   9th   10th   11th   12th What grade

	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 .

	The SECOND BULLY is in
	Kinder - 1st   2nd - 3rd   4th - 5th   6th - 7th   8th   9th   10th   11th   12th What grade

	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 .

	The VICTIM is in
	Kinder - 1st   2nd - 3rd   4th - 5th   6th - 7th   8th   9th   10th   11th   12th What grade

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

	Time of Incident

	Where did the incident occur?
	Where did the incident occur? In the classroom In the hall In the gym In the locker room In the bathroom On the bus Online Other, please specify

	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 .