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DO NOT SUBMIT PERSONALLY IDENTIFIABLE OR
OTHER SENSITIVE INFORMATION IN THIS FORM
Any private information should be discussed directly with the school and not submitted online.
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Directions:
The Bullying, Harassment or Intimidation Reporting Form should be used to report alleged incidents of bullying, harassment, or intimidation that occurred during the current school year on school property, at a school-sponsored activity or event off school property, on a school bus, on the way to and/or from school, or through electronic communication on or off school property. School staff will address incidents that occur at school or have a connection or nexus back to the school setting that create a risk of harm to other students while they are at school or interfere with the educational environment.
If you are a student, the parent/guardian or caregiver of a student, a close adult relative of a student, a school staff member, or a bystander and wish to report an incident of alleged bullying, cyberbullying, harassment, or intimidation, please complete this form, and return it to the school principal.
You may contact the school for additional information or assistance at any time. (Bullying, cyberbullying, harassment, and intimidation definitions are provided below.)
Definitions:
Bullying – is unwanted, demeaning behavior among students that involves a real or perceived power imbalance. The behavior is repeated, or is highly likely to be repeated, over time. In order to be considered bullying, the behavior must be intentional and include: 1) An imbalance of power (students who bully use their physical, emotional, social, or academic power to control, exclude, or harm others), and 2) Repetition (bullying behaviors happen more than once or are highly likely to be repeated based on evidence gathered).
Cyberbullying – is bullying that takes place over digital devices like cell phones, computers, and tablets. Cyberbullying can occur through texting, apps, or online via social media, forums, or gaming where people can view, participate in, or share content. Cyberbullying includes sending, posting, or sharing negative, harmful, false, or hurtful content about another student. It can include sharing personal or private information about someone else causing embarrassment or humiliation.
Harassment – includes actual or perceived negative actions that offend, ridicule, or demean another student with regard to race, ethnicity, national origin, immigration status, family/parental or marital status, sex, sexual orientation, gender identity, gender expression, religion, ancestry, physical attributes, socioeconomic status, physical or mental ability, or disability.
Intimidation – is any communication or action directed against another student that threatens or induces a sense of fear and/or inferiority. Retaliation may be considered a form of intimidation.
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Mandatory fields are marked with an asterisk - *
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Person Reporting Incident
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The Incident
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2. Information About the First Alleged Respondent
Enter whatever information is known about this person
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Information About the Second Alleged Respondent
Enter whatever information is known about this person
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Information About the Third Alleged Respondent
Enter whatever information is known about this person
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3. Alleged Witness
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4. Date(s) Incident(s) Occurred
(At a minimum, the first date is required *)
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5. Check the statement(s) that best describes what happened (choose all that apply) *
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6. Where did the incident happen? (check all that apply) *
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(Retype your name as your signature) By signing this report form, I attest that all information on this form is accurate to the best of my knowledge and I understand the serious nature of this report. By signing this report form, I understand and agree to be contacted by school, local, state or federal authorities to assist in the matters of this report.
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