1.	I have reported this event to my school:*
	-- Please Select --Yes No

2.	WHO got bullied? Please give the first name, last name, and grade level.* This information is required. We cannot follow up on this report unless it is provided.

3.	Please describe what happened. Please include where and when the incident occurred.*

4.	Who was DOING the bullying? Please include first name, last name, and grade level.* This information is required. We cannot follow up on an incident unless it is provided.

5.	Your name (optional):

6.	I am a:
	Student School employee Parent/guardian Person being bullied Community member Friend Other, please specify

7.	Type of bullying (check all that apply):* Select at least 0 and no more than 0.
	Physical bullying- Injury to the person or his/her belongings is characteristic of this method. The bully may have punched, kicked, shoved, or spit on the victim.    Cyber bullying- Takes place in cyberspace. This type of bullying involves various forms of victim harassment, including posting pictures of the victim on websites against his/her wishes and sending pictures through cell phone texting.    Emotional bullying- To exclude the victim from social situations and cause mental pain while leaving the victim feeling alone.    Verbal bullying- The person will say put-downs and rude things directly to the victim, usually in front of his/her friends.    Other, please specify

8.	Were you there when the incident occurred?*
	-- Please Select --Yes No

9.	List other students or adults who witnessed the incident: