Bullying report form

Download Bullying Report Form

This bullying report form can be adapted to suit the circumstances in which it is used, e.g. whether it is used by staff to record details when bullying is reported to them, or whether it is for young people to fill in themselves and post in a Bully Box. These are the basic elements below; you can copy and paste them into your own form or use the Word version above.

Age:

Sex:

Name*:

1. How can we contact you (e.g. at home/at school/email/telephone)?*

2. Describe what happened/is happening.

3. Where did it happen?

4. When did it happen?

5. Who was doing the bullying?*

6. Did anyone else see it happen, and if so who?*

7. Was the bullying a one-off incident or part of a bigger problem?

8. How did the bullying make you feel?

9. Were you physically hurt during the incident?

10. Did you need medical help?

11.  Have you told anyone else about the bullying?

Friend		Teacher
Brother/sister		Youth worker
Parent/carer		Doctor/nurse
Other family member

Other (please tell us who). . . . . . . . . . . . . . . . . . . . . . . . . . . .

12. If you haven’t told anybody else, what has put you off doing so?

13. What sort of help would you like to stop the bullying (e.g. someone to speak to the bullies and monitor the situation to ensure it doesn’t get worse)?

14. Do you have any worries now that you have reported the bullying?

* You don’t have to give any of the information marked with an* if you don’t want to, but if you do you will make it easier for the person looking at this form to help you stop the bullying. Any information given must be treated responsibly and the young person consulted (if name and contact details have been provided) before take any action is taken.