Bullying report form

Name

Your age

Gender

School | PRU | Youth Club | Community Group

HOW CAN WE CONTACT YOU?
by telephone by email by post

Enter your chosen contact information below:

TELEPHONE

EMAIL

ADDRESS

POSTCODE:
-

DESCRIBE WHAT HAPPENED OR WHAT IS HAPPENING

WHERE DID THIS HAPPEN OR WHERE IS IT HAPPENING?

WHEN DID/DOES THIS HAPPEN?

WHO WAS BEING BULLIED?
you a friend someone you don't know

WHO WAS DOING THE BULLYING?
a friend someone you don't know someone at your school someone who lives in your street

WHO WAS DOING THE BULLYING?
a friend someone you don't know someone at your school someone who lives in your street

If it's someone you know, please fill in their name below

DID ANYONE ELSE SEE IT HAPPEN AND IF SO WHO?

WAS THE BULLYING A ONE-OFF INCIDENT OR IS IT PART OF A BIGGER PROBLEM?

HOW DID THE BULLYING MAKE YOU FEEL?

WAS THE PERSON BEING BULLIED PHYSICALLY HURT?
no yes, slightly yes, bruised yes, cut yes, beaten up yes, stabbed

DID YOU/SHE/HE NEED MEDICAL HELP?
yes         no

HAVE YOU TOLD ANYONE ELSE ABOUT THE BULLYING?
yes         no

IF YOU HAVEN'T TOLD ANYONE ELSE, WHAT HAS STOPPED YOU?

IF YOU ARE THE PERSON EXPERIENCING THE BULLYING, WHAT SORT OF HELP WOULD YOU LIKE TO STOP IT (FOR EXAMPLE, SOMEONE TO SPEAK TO THE PEOPLE WHO ARE BULLYING YOU AND KEEP AN EYE ON THE SITUATION TO MAKE SURE IT DOESN'T GET ANY WORSE?)

DO YOU HAVE ANY WORRIES NOW YOU THAT YOU HAVE REPORTED THE BULLYING?

DO YOU WANT BULLYWATCH LONDON TO ACT ON THE INFORMATION YOU HAVE PROVIDED?
IF SO, PLEASE TICK THIS BOX