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Are You Being Bullied or Harassed?
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* Indicates required question
Your Name:
*
Your answer
Date:
*
MM
/
DD
/
YYYY
Where were you when this incident happened?
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Choose
Classroom
Hallway
Cafeteria
Gym
Locker Room
Restroom
Outside
Bus
Other
What happened?
*
Choose
Someone wrote a mean note.
Someone teased me.
Someone started a rumor about me.
Someone called me names.
Someone left me out.
Someone purposely embarrassed me.
Someone told me to do something I didn't like.
Someone started fighting with me.
Someone put his/her hands on me.
Someone said mean things about me on the Internet.
Someone sent me a mean text message or email.
Someone took something of mine.
Someone destroyed my property.
Someone threatened me.
What did you do?
*
Choose
I did something wrong.
I retaliated when someone bothered me.
I called him/her names.
I fought with him/her.
I threatened him/her.
I reported this to an adult.
I destroyed someone's property.
I started a rumor about someone.
I told my parent(s).
I talked about this to a friend.
How I handled my own actions:
*
Choose
Well
Okay
Could have done a better job.
Need help
Poorly
How many times has this happened?
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Once
Multiple Times
Do you need assistance?
I need to speak to a counselor.
I need to speak to the principal.
I need help with my anger.
I need an adult to monitor this area.
I would like an adult to keep this person away from me.
I would like an adult to stop the bullying.
Other:
I would like to see the school prevent bullying or intimidation by . . .
Your answer
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