Solution Team Referral Form (Staff)

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JKMS Staff - Please fill out this form if you are aware of bullying on campus, and think that a student (or group of students) could benefit from a Solution Team. You do not need to get permission from the target before you fill out this referral form, but please include any information that you have. A trained Solution Coach will review this form and follow up with the target. Thank you for advocating for our students!

Terms
Bullying: mean, hurtful behavior that occurs repeatedly in a relationship with an imbalance of power or strength.

Solution Team: A group meeting (meets 3 times) where we focus on building empathy and setting positive goals to support the target. 5-15 minutes per meeting.

Target: the person who is being bullied. The No Bully program discourages using the term "victim."

Bully: the person or people who are engaging in bullying behavior (ex: physical, cyber, verbal, relational)

Physical bullying: physical force to hurt another student; hitting, pushing, shoving, stealing or breaking personal belongings

Cyber-bullying: using texting or social media to threaten, insult, embarrass, impersonate or spread rumors

Verbal bullying: using words to hurt another student; taunting, threatening, insulting, intimidating, name-calling, gestures

Relational bullying: hurting friendships through deliberately leaving a student out, spreading rumors, silent treatment, ostracizing, scapegoating, drawings/words to hurt another student

Harassment: bullying on the topic of perceived or actual differences. Ex: legally protected classes including race, disability, gender, LGBTQ, religion. Administration and/or police are often involved in these cases.

JKMS Solution Coaches: Rebekah, Amy, Jon

Today's Date *

YYYY

Your name: *

Reporting person's name (who told you): *

Target's name (the student who is being bullied): *

Bully's name, leader(s) of the bullying: *

Bully-followers' names (other students that contribute to the bullying but aren't the ringleader):

Bystander's names (students who do not stand up for the target, but are silent witnesses to the bullying):

Allies/supportive friends of the person being bullied:

Positive leaders on campus. (Supportive/empathetic/kind/helpful students who the "target" may be around in class, at lunch, passing period, etc. These students do not necessarily have to know or be friends with the "target", but are positive role models on campus):

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