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Section 1 of 3
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Bullying
Cyberbullying
Self Harm
Suicide Concern
Suspect Abuse or Neglect
Family Crisis
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Section 2 of 3
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Physical: Hitting, kicking, or other physical aggression
Verbal: Teasing, name calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad
Emotional/Exclusion: Starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends
Cyber-bullying: Using an electronic device (texts, emails, phone messages, Facebook, etc.) to engage in any of the previously mentioned "bullying"
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1.
Yes
2.
No
3.
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Student
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Community Member
Friend
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Section 3 of 3
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Friend
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Who are you concerned about?
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IhVnvnfnfn cfcNature of concern is:
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Bullying
If bullying is suspected, does it meet the definition of bullying? A person is being bullied when he or she is exposed, repeatedly and over time, to negative actions on the part of one or more persons (Olweus, 1986, 1993). Characteristics of bullying are: the behavior is aggressive or malicious, it is repeated and goes on over time, it occurs in an interpersonal relationship which is characterized by a certain imbalance in strength or power.
If yes, what is the name of the bully:
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Type of Bullying (select all that apply):
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Description of events:
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Did you witness the bullying?
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Your name (Optional):
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I am a:
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Concern
Concern other than bullying:
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Your name (Optional):
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I am a:
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The administrators will investigate the report and take appropriate actions to deal with the situation. Since much of what we do needs to remain confidential, you may not know of the steps we take to address each concern. If your concern does not improve, we need to take additional steps. Please let us know.
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