Bully's Name:

Main Bully's First Name

Main Bully's Last Name

Please try to give us a name or nickname. Don't worry about the spelling, spell it like it sounds.

Second Bully's Name:

Second Bully's First Name

Second Bully's Last Name

If there was a second Bully or a person helping the Bully put their name on this line.

Victim's Name:

Victim's First Name

Victim's Last Name

You can use any name including nicknames.  Don't worry about the spelling, spell it like it sounds. If it was you then put your name.

Date/Time of Incident:

Date

(Example: 03/25/2013)

Time

(Example: 1:30 pm)

Do the best you can to remember the date and time.  You can click HERE for a calendar.

Do you know these people?:

None My Friend Not My Friend

Main Bully

None My Friend Not My Friend

Second Bully

None My Friend Not My Friend Me

Victim

Location :

Where did the incident happen?

Description

Tell us what the Bully did to the Victim.

Witnesses/ By- Standers:

Please give us the names of witnesses or bystanders who might also have seen this happen besides you.

Other Information That Might Help Us

 

Race:

 

Unknown White Hispanic Black Other

Bully

 

Unknown White Hispanic Black Other

Second Bully

 

Unknown White Hispanic Black Other

Victim

Gender:

 

None Selected Male Female

Bully

 

None Selected Male Female

Second Bully

 

None Selected Male Female

Victim

Grade:

 

Unknown 1 2 3 4 5 6 7 8 9 10 11 12

Bully

 

Unknown 1 2 3 4 5 6 7 8 9 10 11 12

Second Bully

 

Unknown 1 2 3 4 5 6 7 8 9 10 11 12

Victim

Your Information is Optional But Appreciated

WE PROMISE TO PROTECT YOU

Your Name:

 

First Name

 

Last Name

Contact Info:

 

Phone Number

 

Email Address

Grade and ID:

 

Unknown 1 2 3 4 5 6 7 8 9 10 11 12

Your Grade

 

Your ID Number