Speak Up!
Report Bullying!
Your name or Student ID (Optional):
Your Grade (Optional):
How did you find out about this:
You were bullied
Witnessed bullying
Heard about bullying
Where did this happen:
When did this happen
Date:
Time:
Who did the bullying:
What type of bullying:
Social (Gossip)
Verbal (Name calling)
Physical (Hit)
Other
If other, please explain
Would you like to be contacted about this?
no
yes
(If yes, name or ID must be included on form)
If yes, by whom?
Counselor
Teacher
Administrator
Explain what happened in your own words
