L. C. Schmitt Elementary Bully Reporting Survey
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Name of person being bullied.
Date bullying occurred:
Name of bully:
I am a:
I am a:
Person being bullied
Type of bullying (select all that apply):
Physical - Hitting/kicking/other physical aggression
Verbal - Teasing/name-calling/put-downs/behavior that hurts one's feelings
Emotional/Exclusion - Starting rumors/telling others not to be friends with someone/actions that would cause someone to be without friends
Cyber - Use of electronics (text, IM, email, internet, Facebook/Myspace) to achieve any of the actions
Describe what happened (Please be specific including location, date/time, etc.):
Did you see the bullying?
-- Please Select --
List other people that saw the bullying:
Would you like to be contacted about this incident? (Optional) If so, include name and phone number.
Just an example.