Circle One:
Bully Report or Conflict Report
Name:
Date:
The name of the person or persons bullying me:
Short Description of what has been happening:
I am being bullied and this is what I have tried to do:
I did nothing
I feel alone
I feel angry
Talked to my parent about it
Told them to stop
Tried to ignore it
Walked away
Told a teacher or adult at school
Asked a friend for help
I feel frightened or scared.
Action Taken (Staff Use Only):
Referral to counselors
Called Home
Referral to principals
Mediation with Counselor
Parent Meeting
Principal Mediation
Date Action Taken
Comments: