Bullied?

Please provide as much detail as possible to help us deal with the problem effectively.

Name of person being bullied(*)

Please enter the name of the person being bullied.

Date(*)

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Name of bully(*)

Please enter the name of the bully.

Your Name (optional)

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I am a(*)

Type of Bullying (Select all that apply)(*)

Physical - Hitting/kicking/other physical aggression.

Verbal - Teasing, name calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad.

Emotional/Exclusion - Starting rumors, telling others not to be friends with someone or other actions that would cause someone to be without friends.

Cyber-bullying - Using an electronic medium (including but not limited to: texts, e-mails, phone messages, facebook, etc.) to engage in any previously mentioned "bullying."

Please select the type of bullying.

Description of events
(Please be specific - use exact wording, names, dates, location and time, etc.)(*)

Please describe the event.

Did you witness the bullying?(*)

YesNo Please specify yes or no.

Please list other students/staff who may have witnessed the bullying incident described above

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The administrators will investigate the report and take appropriate actions to deal with the situation. Since much of what we do needs to remain confidential, you may not know of the steps we take to stop the bullying. If the bullying does not stop, we need to take additional steps. Please let us know if the bullying continues.

Human Verification

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Immanuel Lutheran School Bully Reporting Form