1. My name is __________________________________________.
2. The person that is bullying me or someone else is ______________________________________________________.
3. If you are reporting a bullying problem about someone else, what is the victim’s name? _____________________________________.
4. This is what the person is doing to hurt my/someone else’s feelings or, hurt my/someone else’s things or hurt my/someone else’s body . (IF THE PERSON HURTS YOUR BODY, TELL AN ADULT RIGHT AWAY!)__________________________________________________
TELL ME WHAT YOU HAVE DONE TO TRY TO SOLVE THIS PROBLEM ON YOUR OWN
(Please put this in the Bully Buster Box after you have tried ALL 5 THINGS BELOW and the bullying is still a problem):
Circle all of the solutions you have tried.
1. I have ignored the bully. 2. I have walked away from the bully. 3. I have asked my parents to give me some ideas. 4. My friends and I have talked to the bully as a group. 5. I have told my teacher about this problem more than 3 times.
Please get a teacher signature before turning this form in to the Bully Buster Box.