Bully Report

Peacock Bully Report

Please report on incidents that you have heard or witnessed

 
I am a: *
Target of bullying
Witness
Staff member
Parent/Guardian
Community Member
* Other
 
Today's date *
Name of Alleged Bully *
What date did the incident occur? *
What time of day did the incident occur?
 
Where did the incident occur? *
Hallway
Classroom
Bathroom
Lunch
Recess
Gym
On the bus
Bus stop or on the way to/from school
Library
* Other

Type of bullying (may be more than one)

Relational/Emotional Aggression
 
Starting rumors
 
Excluding an individual
 
Telling others not to be friends with someone
 
Physical Aggression
 
Hitting/Kicking
 
Verbal Aggression
 
Teasing
 
Name Calling
 
Put downs
 
Behavior that would hurt feelings.
 
Cyberbullying - Texting
 
Cyberbullying - Social networks (Facebook, etc.)
 
Cyberbullying - Email
 
Cyberbullying - Other electronic means
 
Other
 
Has the alleged bully done this to the same victim on other occasions?*
Yes
No
I don’t know
 
Please describe the incident that occurred. Be as specific and accurate as possible. *
 
Your name and grade (Optional)
 
 
 


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