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Student Bullying Report
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* Indicates required question
Email
*
Your email
Name:
*
Your answer
Grade level:
*
4th grade
3rd grade
2nd grade
1st grade
Kindergarten
Child Development
Name of student you believe is bullying you:
*
Your answer
Examples of what this student has done to you:
*
Your answer
Where did these things happen?
*
Classroom
Playground
Cafeteria
Bus
Other
Required
Has this happened more than once?
*
Yes
No
If yes, how often?
Your answer
Are you friends with this person?
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Yes
No
Have you told any other adults about this?
*
Yes
No
If so, who have you told?
Your answer
Do you often choose to be around this person?
*
Yes
No
Do you believe this person has more power than you?
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Yes
No
If yes, how?
Your answer
Bullying is defined as "unwanted aggressive behavior that is repeated over time and involves an imbalance of power." Based on this definition, do you believe the student you named is truly bullying you?
*
Yes
No
I have been honest in answering this form. I understand that in a true bullying situation, the school counselor cannot keep private what I have told her, and she will likely bring this to the attention of the principal or assistant principal.
*
Yes
No
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