Name of Person Being Bullied:

Your Name(optional)

Name of Bully:

School: Don't Know Adams Elementary Armstrong Elementary Audubon Elementary Bancroft Elementary Kennedy Elementary Lincoln-Jackson Marshall Elementary McNichols Plaza Morris Elementary Prescott Elementary Sumner Elementary Whittier Elementary Willard Elementary Northeast Intermediate South Scranton Intermediate West Scranton Intermediate Scranton High School West Scranton High School

Date of Incident:

I am a: Student Parent/Guardian Staff Person Community Member Target Friend

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: Starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends
Cyber: Using electronic device mediums such as but not limited to computers, cell phones, and pagers to bully others through methods such as posting comments, statements, or pictures on blogs or websites, text messaging, instant messaging and email.

Description of Events (Please be specific Location/Date/Time):

List other students/staff who witnessed the bullying: