Bullying Form: Pine Village

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Definitions: Bullying is unwanted, repeated, aggressive behavior among school age children that involves a real or perceived power imbalance. Although this form is anonymous, we are not able to follow up with concerns if details are not provided.

Email *

Watch the Video- Is it Bullying?

Name of student reporting? (Your Name) *

Name of student you believe is bullying you or others? *

Do you chose to be around this person? *

Yes

Are you friends with this person? *

Yes

What type of bullying has occurred? *

Physical: bullying with aggressive physical intimidation, involves repeated hitting, kicking, tripping, blocking, pushing, and touching in unwanted and inappropriate ways.

Verbal: bullying with cruel words spoken. Involves name-calling, threatening, and making disrespectful comments about someone's attributes (appearance, religion, ethnicity, disability, etc.)

Social/Relational: bullying with exclusionary tactics. Involves deliberately preventing someone from joining or being part of a group, whether it's at a lunch table, game, sport, social activity, etc.

Cyber: bullying in cyberspace or by using digital technology. Taunting or humiliation through social media sites or the Internet, cruel websites targeting specific youth, humiliating others while playing online games, verbal or emotional bullying through chat rooms, instant message.

Examples of what this person has done to you - be specific *

Where have these things happened? *

Bus

Classroom

Cafeteria

Hallway

Library

Restroom

Social Media

Recess

Required

Who else have you told? *

Parent

Trusted adult at home

Friends

Classmates

Teacher

Other:

Required

A copy of your responses will be emailed to the address you provided.

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