Definition of bullying: an overt, unwanted, repeated act or gesture, including written or verbal communications or images transmitted in any manner, physical acts, or any other behaviors that are committed by a student or group of students against another student with the intent to harass, ridicule, humiliate, intimidate, or harm the other targeted student and create for the targeted student an objectively hostile school environment.

Name of person being bullied: *
Name of bully: *
Today's Date *
Your contact info - (Optional):
phone no., email, etc.
I am a: (Select all that apply)

TYPE OF BULLYING (Select all that apply)

Did you witness the bullying?
DESCRIPTION OF EVENTS: (Please be specific-Location/Date/Time):