Appendix 3

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Appendix 3 Template for recording bullying behaviour

 

1. Name of pupil being bullied and class group

 

Name                                                                                               Class                                         

 

2. Name(s) and class(es) of pupil(s) engaged in bullying behaviour

 

3. Source of bullying concern/report

(tick relevant box(es))*


4. Location of incidents (tick relevant box(es))*

Playground

 

Classroom

 

Corridor

 

Toilets

 

School Bus

 

Other

 


 

 

5. Name of person(s) who reported the bullying concern

 

Pupil concerned

 

Other Pupil

 

Parent

 

Teacher

 

Other

 

 

 

6. Type of Bullying Behaviour (tick relevant box(es)) *

 

Physical Aggression

 

Cyber-bullying

 

Damage to Property

 

Intimidation

 

Isolation/Exclusion

 

Malicious Gossip

 

Name Calling

 

Other (specify)

 

 

7. Where behaviour is regarded as identity-based bullying, indicate the relevant category:

 

Homophobic

Disability/SEN

related

Racist

Membership of

Traveller community

Other (specify)

 

 

 

 

 

 

8. Brief Description of bullying behaviour and its impact

 

 

 

 

 

 

 

9.    Details of actions taken

 

 

 

 

 

 

 

Signed                                                                       (Relevant Teacher)   Date                                                                        

 

Date submitted to Principal/Deputy Principal

* Note: The categories listed in the tables 3, 4 & 6 are suggested and schools may add to or amend these to suit their own circumstance