Huntsville City Schools -

Directions: Bullying, harassment, or intimidation is serious and will not be tolerated. This is a form to report alleged bullying, harassment, or intimidation that occurred on school property, at a school-sponsored activity or event off of school property, on a school bus, or on the way to and/or from school in the current school year. If you are a student victim, the parent/guardian of a student victim, a close adult relative of a student victim, or a school staff member, and wish to report an incident of alleged bullying, harassment or intimidation, please complete this form. Once complete, the results of this form will automatically be sent to the principal at the student victim’s school.

The results of this form will be monitored between the hours of 7:00am - 5:00pm during the school year. Any reports submitted outside of these hours, or during holidays, will be investigated during the following normally scheduled school day. Please do not use this system for issues requiring immediate assistance. If this is an emergency requiring immediate assistance, please call 911. Contact the school directly for additional information or assistance during posted office hours.

What Counts As Bullying?

Bullying is any intentional and repeated act of unwanted aggressive or demeaning behavior involving a real or perceived power imbalance that takes place on or off school property, in which one or more people intentionally and repeatedly cause physical or psychological harm to another person. To be considered bullying, the conduct must also place a student in reasonable fear of harm or of damage to property, have the effect of substantially interfering with educational performance or school operation, or create a hostile, intimidating, threatening, or abusive educational environment.

The information provided on this form is considered, and will be kept, confidential.

Bullying, Harassment, or Intimidation Report

59 Questions

1) Power Imbalance: *

The incident(s) you are reporting involve a real or perceived power imbalance (answer must be "yes" to proceed). Reminder: Bullying is any intentional and repeated act of unwanted aggressive or demeaning behavior involving a real or perceived power imbalance that takes place on or off school property, in which one or more people intentionally and repeatedly cause physical or psychological harm to another person.

2) Repetition *

The incident(s) you are reporting involve *repeated* physical or psychological harm (answer must be "yes" to proceed"). Reminder: Bullying is any intentional and repeated act of unwanted aggressive or demeaning behavior involving a real or perceived power imbalance that takes place on or off school property, in which one or more people intentionally and repeatedly cause physical or psychological harm to another person.

3) School where the incident occurred *

School where incident occurred.

4) Person Reporting Incident: Reporter Name *

Enter the name of the person reporting the incident. (Smith, John)

5) Person Reporting Incident: Phone *

6) Person Reporting Incident: Email Address *

Please enter the email address for the person reporting.

7) Person Reporting Incident: Position *

Please select the most appropriate option.

8) Alleged Student Victim 1: Name *

Please enter the name of the alleged first student victim. (Smith, John)

9) Alleged Student Victim 1: Age *

10) Alleged Student Victim 1: School *

Please select the school this alleged victim attends.

11) Alleged Student Victim 1: Grade *

Please select this alleged victim's grade level.

12) Alleged Student Victim 2: Name (optional)

Please enter the name of the alleged second student victim. (Smith, John)

13) Alleged Student Victim 2: Age (optional)

14) Alleged Student Victim 2: School (optional)

Please select the school this alleged victim attends.

15) Alleged Student Victim 2: Grade (optional)

Please select this alleged victim's grade level.

16) Alleged Student Victim 3: Name (optional)

Please enter the name of the alleged third student victim. (Smith, John)

17) Alleged Student Victim 3: Age (optional)

18) Alleged Student Victim 3: School (optional)

Please select the school this alleged victim attends.

19) Alleged Student Victim 3: Grade (optional)

Please select this alleged victim's grade level.

20) Alleged Witness 1: Name (optional)

Please enter the name of the alleged first alleged witness. (Smith, John)

21) Alleged Witness 1: Age (optional)

22) Alleged Witness 1: School (optional)

Please select the school this alleged witness attends, if applicable.

23) Alleged Witness 1: Position (optional)

Please select the most appropriate option.

24) Alleged Witness 2: Name (optional)

Please enter the name of the alleged second alleged witness. (Smith, John)

25) Alleged Witness 2: Age (optional)

26) Alleged Witness 2: School (optional)

Please select the school this alleged witness attends, if applicable.

27) Alleged Witness 2: Position (optional)

Please select the most appropriate option.

28) Alleged Witness 3: Name (optional)

Please enter the name of the alleged third alleged witness. (Smith, John)

29) Alleged Witness 3: Age (optional)

30) Alleged Witness 3: School (optional)

Please select the school this alleged witness attends, if applicable.

31) Alleged Witness 3: Position (optional)

Please select the most appropriate option.

32) Alleged Offender 1: Name *

(Smith, John) Enter "Unknown" if not known.

33) Alleged Offender 1: Age *

Enter age if known.

34) Alleged Offender 1: School (optional)

Please select the school this alleged offender attends, if applicable.

35) Alleged Offender 1: Position *

Please select the most appropriate option.

36) Alleged Offender 2: Name (optional)

(Smith, John) Enter "Unknown" if not known.

37) Alleged Offender 2: Age (optional)

Enter age if known.

38) Alleged Offender 2: School (optional)

Please select the school this alleged offender attends, if applicable.

39) Alleged Offender 2: Position (optional)

Please select the most appropriate option.

40) Alleged Offender 3: Name (optional)

(Smith, John) Enter "Unknown" if not known.

41) Alleged Offender 3: Age (optional)

Enter age if known.

42) Alleged Offender 3: School (optional)

Please select the school this alleged offender attends, if applicable.

43) Alleged Offender 3: Position (optional)

Please select the most appropriate option.

44) Date and time of Incident *

SUN

MON

TUE

WED

THU

FRI

SAT

45) Date and time of 2nd Incident (optional)

SUN

MON

TUE

WED

THU

FRI

SAT

46) Date and time of 3rd Incident (optional)

SUN

MON

TUE

WED

THU

FRI

SAT

47) Location of Incident(s) *

Check all that apply.

On School Property

At a School-Sponsored Activity or Event Off of School Property

On a School Bus

On the Way To/From School

Via Internet-Sent Off School Property

Via Internet-Sent On School Property

48) Nature of Incident(s) *

Check all that apply.

Bullying, Harassment, or Intimidation Which Involves Physical Aggression

Getting Another Person to Hit or Harm the Student

Teasing, Name-Calling, Making Critical Remarks or Threatening, In-Person or by Other Means

Demeaning and/or Making the Victim of Jokes

Making Rude and/or Threatening Gestures

Excluding or Rejecting the Student

Related to the Student's Disability

Related to the Student's Perceived Sexual Orientation

Spreading Harmful Rumors or Gossip

Intimidating, Extorting, or Exploiting

Cyber Bullying (e.g. social media including Facebook, Twitter, Vine, Snapchat, Periscope, Kik, Inst

Electronic Communications (e.g. email, text, sexting, etc.)

Gang Related

Human Trafficking/Prostitution Recruitment

Gang Recruitment

Racial Harassment

Other (specify below)

Sexual Harassment

Sexual in Nature

49) Details of Incident (optional)

50) Motive of Incident(s) *

Why did the bullying, harassment, or intimidation occur? (Check all that apply.)

Because of Race

Because of Color

Because of National Origin

Because of Marital Status

Because of Sex

Because of Sexual Orientation

Because of Nonconformity to Sex Stereotypes

Because of Gender Identity

Because of Gender Expression

Because of Religion

Because the Student Acts Stereotypically Male/Female (for example, teasing a male for being effemin

Because of Disability

Because of Physical Appearance

To Impress Others

Just to be Mean

Gang Related

Gang Recruitment

Human Trafficking/Prostitution Recruitment

Other (specify below)

51) Details of Motive (optional)

(If known)

52) Physical Injury *

Did a physical injury result from this incident?

Yes, but it did not require medical attention.

Yes, and it required medical attention

53) Permanent Physical Injury *

If a physical injury was selected above, do you think there will be permanent effects? (Select NO if there was no physical injury.)

Yes

54) Psychological Injury *

Did a psychological injury result from this incident?

Yes, but psychological services have not been sought.

Yes, and psychological services have been sought.

55) Suicidal Thoughts *

Has the student made or reported any threat of suicide, or suicidal thoughts?

Yes

56) Absences *

Was the student victim absent from school as a result of the incident?

Yes

57) Days Absent *

How many days was the student victim absent from school as a result of the incident? Enter 0 if the student did not miss any days.

58) Injury Details (optional)

Please list any additional details regarding the injury.

59) Additional Information (optional)

Is there any additional information you would like to provide?

Huntsville City SchoolsP.O. Box 1256Huntsville, AL 35807-4801(256) 428-6800

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IN ACCORDANCE WITH THE REQUIREMENTS OF TITLE II OF THE AMERICANS WITH DISABILITIES ACT OF 1990 ("ADA"), THE HUNTSVILLE CITY BOARD OF EDUCATION WILL NOT DISCRIMINATE AGAINST QUALIFIED INDIVIDUALS WITH DISABILITIES ON THE BASIS OF DISABILITY IN ITS SERVICES, PROGRAMS, OR ACTIVITIES. FOR MORE INFORMATION PLEASE CONTACT THE COMPLIANCE DEPARTMENT.