Report a Bully 2009-2010 Survey

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1. Name of person allegedly being bullied:

Name of person allegedly being bullied:

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2. Date of alleged bullying event:

Date of alleged bullying event:

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3. Name of alleged bully/bullies:

Name of alleged bully/bullies:

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4. The alleged bully is:

The alleged bully is: A student

A school employee

5. Your Name (optional)

Your Name (optional)

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6. I am a:

I am a: Community Member

Friend

Parent/Guardian

Person being bullied

School Employee

Student

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7. Type of Event (Select all that apply):

Type of Event (Select all that apply): CyberBullying - Using an electronic medium to engage in any previously mentioned bullying

Emotional/Exclusion - Starting rumors, telling others not to be friends with someone, or other actions that would cause someone to be without friends

Physical - Hitting/kicking/other physical aggression

Verbal - Teasing, name-calling, put-downs, or other behavior that would hurt others’ feelings or make them feel bad

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8. Description of events (Please be specific - Location/Date/Time):

Description of events (Please be specific - Location/Date/Time):

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9. Did you witness the event?

Did you witness the event? No

Yes

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10. List other students/staff who witnessed the event:

List other students/staff who witnessed the event:

Report a Bully 2009-2010
Exit this survey

1. Default Section

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1. Name of person allegedly being bullied:

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2. Date of alleged bullying event:

*
3. Name of alleged bully/bullies:

*
4. The alleged bully is:

5. Your Name (optional)

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6. I am a:

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7. Type of Event (Select all that apply):

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8. Description of events (Please be specific - Location/Date/Time):

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9. Did you witness the event?

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10. List other students/staff who witnessed the event:

Report a Bully 2009-2010Exit this survey

1. Default Section

*1. Name of person allegedly being bullied:

*2. Date of alleged bullying event:

*3. Name of alleged bully/bullies:

*4. The alleged bully is:

5. Your Name (optional)

*6. I am a:

*7. Type of Event (Select all that apply):

*8. Description of events (Please be specific - Location/Date/Time):

*9. Did you witness the event?

*10. List other students/staff who witnessed the event:

Report a Bully 2009-2010
Exit this survey

*
1. Name of person allegedly being bullied:

*
2. Date of alleged bullying event:

*
3. Name of alleged bully/bullies:

*
4. The alleged bully is:

*
6. I am a:

*
7. Type of Event (Select all that apply):

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8. Description of events (Please be specific - Location/Date/Time):

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9. Did you witness the event?

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10. List other students/staff who witnessed the event: