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A Note For A Friend
Name
First
Last
Date Time
MM
/
DD
/
YYYY
Classroom Teacher of the student that was being bullied
Who (do you think) was being bullied?
*
When did this happen?
*
Where did this happen?
*
What took place: (check all that apply)
*
Called Mean Names
Threatened
Spread Rumors
Cyber-Bullying
Left Out/Exclusion
Hit, Kicked, punched
Offensive Comments
Who have you notified: (check all that apply)
*
Principal
Assistant Principal
Teacher
Teacher Assitant
Guidance Counselor
Parent
Classmates
Nobody Yet
Is this the first time that this has happened?
Yes
No
Have you dropped a note for a friend before?
Yes
No
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