THE BULLY PERISCOPE

BULLY REPORTING FORM

Dear Victims and Witnesses,

The first step to reporting bullying through The Bully Periscope is to confirm that the incident meets the standards to be labeled as a bullying incident. Bullying occurs when a student with an advantage in size, strength, stature or standing uses that advantage to harm another student physically or with their words or actions. Bullying may inflict distress or harm on the targeted youth including physical, psychological, social, or educational harm.”

Please, only report incidents that meet the above standards for bullying.

Bully Incident Report

Victims/Witnesses

Victims/Witnesses – Please check one of the boxes below:

To give my report maximum credibility I have a trusted adult who will pass questions and answers back and forth for me. This gives me the ability to remain anonymous while still being available to answer questions. My trusted adult’s email address is on the bully reporting form.

I am a student/staff member in your school who wishes to remain anonymous without a trusted adult.

I am a student/staff member in your school who does not seek anonymity.

Full Name

Phone Number

Bully Information

Complete School Name

School ZIP Code

Full name of bully

Gender of bully

Grade of bully

Homeroom Teacher Of Bully (last name only)

Principal Email Address

Incident Information

Today's Date

Trusted Adult Email

Bullying Incident Details

Date of Incident

Where did this incident occur?

What time did this incident occur?

What is the victim’s name?

Did the bully physically abuse the victim?

Was the victim a handicapped student?

Was the victim a younger or smaller student than the bully?

If more than one bully was involved add their names here

Names of all students who were witnesses to this incident

Names of any other students that cheered on the bully’s actions

Did any teacher or staff member see this incident?

If yes, who was the teacher / staff member?

What actions did the teacher / staff member take?

Did you video this bullying incident?

If the answer is yes, please provide an email address where we can get access to your video if needed to prove the case.

In complete detail provide all information you have on this incident. Start at the very beginning before the abuse started; first, pinpoint where the bully and victim were sitting/standing and then tell what happened from that point.

Have you witnessed this bully abusing other students in the past? If Yes, please provide any details of other bullying incidents that you have witnessed or seen in the past involving this bully.

Legal Acknowledgment

I certify that the information provided is truthful to the best of my knowledge and understand this report may be reviewed by authorized attorneys.

THE BULLY PERISCOPE

THE BULLY PERISCOPE

BULLY REPORTING FORM

Victims/Witnesses

Bully Information

Incident Information

Bullying Incident Details

Legal Acknowledgment

Practice Area

Useful Links

Contact Info