Bully Box

	Who was involved with the situation/behavior (all persons)?

	What is the bullying situation or behavior that happened?

	Where did the situation or behavior occur?

	When did the situation or behavior occur?
	Before School    During School    After School    Outside of School    Other, please specify

	Have you talked to anyone else about what has happened?
	Have you talked to anyone else about what has happened? YesNo

	Is there anything else that you would like me to know?

	Person submitting the referral (optional - your name will only be used if we need additional information):