Date of incident:
Name of victim:
Name of bully:

Tick which of the following type(s) of bullying occurred:
Name calling
Issuing verbal threats
Isolating an individual
Teasing
Demanding or taking money
Forcing someone to steal
Physical violence eg hitting, kicking
Demanding or taking other's possessions
Deliberately damaging someone's schoolwork or equipment
Non-verbal threats eg 'the look', signs etc.

Other

Tick where the bullying occured:
Playground
Cloakroom
Dining Hall
Toilets
Way to school
Corridors
In class
Way home

Any other places?

Any additional information?