“I
HAVE BEEN HASSLED…”
Name __________________________ Teacher _____________ Date __________
Who bullied you? ______________________________ Teacher_____________________________
When did the problem happen?
_____ Before School _______ During School _____ After School
Where were you?
_____ Classroom _____ Bathroom _____ Lunchroom _____ Halls
_____ P.E. _____ Playground _____ Bus _____ Other________________
How did the problem start?_________________________________
What exactly did that person say or do to you?_______________________________ ____________________________________________________________
____________________________________________________________
____________________________________________________________
What did you do? (check all that you have tried)
_____ Hit back _____ Told adult _____ Ran away _____ Walked away calmly
_____ Yelled _____ Told friend _____ Cried _____ Told them to stop it
_____ Told bus driver _____Used Anger Control (deep breath) _____ Other__________________
What happened as a consequence of your choice?___________________________________
I care statement:
When___________________________________________________________________________
I felt____________________________________________________________________________
I want___________________________________________________________________________
Student Signature _________________________________________ Date_______________________
Parent Signature __________________________________________ Date_______________________
Return form to principal, Mrs. Nolz, Mrs. Tucholke or Mrs. Will
