Alternate Learning Center

Bullying Reporting Form

Return to Mrs. Theiss’ "Counseling Box" or to a school staff member.

Optional
Your name:   	

Your grade:   	

Bully's name:   	

Bully's grade:   	

Circle where the bullying happened:

Classroom               Hallway                   Bathroom                Playground Art/ Gym                  Outside of School   Internet                    Cell Phone Outside of school building on school property
Other:

Circle when the bullying happened:

Before School                    Morning

Lunch Time                        Afternoon                After School

Other: (time, if unknown):

Circle what happened. "I was”	or	"I saw someone get"

hit      kicked           pushed         teased          laughed at

excluded on purpose	cyber-bullied (internet/ cell phone) Other:
Describe the incident to the best of your ability: