Bullying Report Form Your Name: *Relationship to victim: Parent Grandparent Guardian Friend Other If reported to you by someone else, indicate who: *Date(s) of Incident:: *Type of Bullying?: Verbal Non-verbal (exclusion, eye-rolling, etc...) Physical Cyber-bullying Other *Who was Bullied? (Please list first and last names and grade level of all students, if reporting multiple students.) *Who did the Bullying? (Please list first and last names and grade level of all students, if reporting multiple students.) Were there any bystanders? If yes, please list first and last name. Where did it happen? Time of day? Morning Lunch/Recess Afternoon Has this happened before? NO, this is the first time. YES, this has happened once before. This is an ongoing problem. *Briefly describe the incident Any other information we need to know?