VHS Bullying Prevention

VALMEYER BULLYING FORM

Your name: ___________________________ Grade:_______ Date: ______

Place an X in the box of the correct statement and fill in names (if possible).

Was bullied By whom? _______________________________

Witnessed bullying Victim ____________________________

Bully _____________________________

Where did the incident happen (choose all that apply)?

____On school property

if yes where: _______________________________

____At a school-sponsored activity or event off school property

____On a school bus

____On the way to/from school (circle one)

Place an X next to the statement(s) that best describes what happened (choose all that apply):

____Hitting, kicking, shoving, spitting, hair pulling, or throwing

something

____Getting another person to hit or harm the student

____Teasing, name-calling, making critical remarks, or threatening, in

person or by other means

____ Making the victim of jokes

____ Making rude and/or threatening gestures

____Excluding or rejecting the student

____Intimidating (bullying), extorting, or exploiting

____Spreading harmful rumors or gossip

____other: _________________________________________________

Please return this form to the purple bully box in the library or to any staff member.

Thank you for helping us make Valmeyer a safe place to learn!

VCUSD Home

High School Home