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DJH Bullying Referral Form
Please provide as much detail as possible to help us deal with the problem effectively
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* Indicates required question
Name of person(s) being bullied:
*
Your answer
Date:
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MM
/
DD
/
YYYY
Name of bully (bullies):
*
Your answer
Your name optional:
Your answer
I am a:
*
Student
Staff member
Parent/Guardian
Person being bullied
Community member
Friend
Type of bullying: Select all that apply:
*
Physical - Hitting/kicking/other physical aggression
Verbal - Teasing, name calling, put-downs, or other behavior that would hurt other's feeling or make them feel bad
Emotional/Exclusion - Starting rumors, telling others not to be friends with someone, or actions that would cause someone to be without friends
Cyber-bullying - Using an electronic medium including but not limited to emails, phone messages. texts, social media to engage in any previously mentioned 'bullying"
Description of events: (please be specific - use exact wording, names, dates. location and time, etc.)
*
Your answer
Did you witness the bullying?
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Yes
No
Please list other students /staff who may have witnessed the bullying incident described above:
*
Your answer
Have you talked to any other adult in the building about this? If so, who?
*
Your answer
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