Bullying Form

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

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.

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.

School where incident occurred.

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

Please enter the email address for the person reporting.

Please select the most appropriate option.

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

Please select the school this alleged victim attends.

Please select this alleged victim's grade level.

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

Please select the school this alleged victim attends.

Please select this alleged victim's grade level.

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

Please select the school this alleged victim attends.

Please select this alleged victim's grade level.

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

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

Please select the most appropriate option.

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

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

Please select the most appropriate option.

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

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

Please select the most appropriate option.

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

Enter age if known.

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

Please select the most appropriate option.

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

Enter age if known.

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

Please select the most appropriate option.

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

Enter age if known.

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

Please select the most appropriate option.

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

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

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)

(If known)

Did a physical injury result from this incident?

No
Yes, but it did not require medical attention.
Yes, and it required medical attention

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

Yes
No

Did a psychological injury result from this incident?

No
Yes, but psychological services have not been sought.
Yes, and psychological services have been sought.

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

No
Yes

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

Yes
No

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.

Please list any additional details regarding the injury.

Is there any additional information you would like to provide?