Bullying Report Form

Bullying Report Form

Does what happened fit all three parts of bullying?
1. It is repeated?
2. There is an imbalance of power.
3. The person is being mean on purpose and wants to do harm.





Name of targeted student: 

What happened? 

What was happening before the problem? 

When did it happen? 

Where did it happen?
 Bus     Playground     Hallway     Bathroom      Cafeteria      Classroom


Who was bullying? 

Was an adult told? 

If so, who was told? 

What did the adult say the student should do? 

Did the student do what the adult said?   * Yes    No

If so, did it help?   * Yes      No

Names of others who saw this happening: 



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