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Report Bullying

You can use this survey form to report bullying. The responses will be given to Mrs. Kaiser, Mrs. Mendez and Mr. Wiggans.

If you want bullying stopped, we must have detailed information.
Name: 


A red asterisk (*) indicates required questions.

The bullying happened
at school
at home/in my neighborhood
at the mall
online (email, IM, chat)
on the phone
other


The bullying happened
once
twice
three times
four times
more than four times


The bullying was
physical (hitting, pushing, kicking, etc.)
emotional (teasing, name calling, putting down, etc.)
social (ignoring, turning friend against, rumors, etc.)
Other


Did anyone else witness the bullying?
Yes
No


If you wish, please give the name(s) of the witness(es).


Have you told anyone else about this bullying?
parent(s)
brother/sister
other relative
friend
trusted adult
teacher/counselor/principal
other
no


Please tell as much as possible out the bullying. Don't be afraid to use the words that were actually said.*


On a scale of 1 to 3 where 1 means "not much", 2 means "some" and 3 means "a lot", please rate how much the bullying bothers you.
1 2 3


Do you know why this person is bullying you?
Yes
No


Do you want to talk to a counselor or Mr. Wiggans?
Mrs. Kaiser
Mrs. Mendez
Mr. Wiggans
No


What is the bully's name? (Note: you do not have to name the bully and if you do not know the bully's name, please describe him/her).