Bullying, Harassment, or Intimidation Reporting Form

Maryland State Department of Education in accordance with the Safe Schools Reporting Act of 2005

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.
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.
Mandatory fields are marked with an asterisk - *
School
Person Reporting Incident
Name Name First Last
Phone Phone - ### - ### ####
Email
Relationship to Target
The Incident
1. Target Student's Name 1. Target Student's Name First Last
Age of Target
Grade of Target
Number of Alleged Respondents (1-3)
Days student absent as a result of the incident (if known):
2. Information About the First Alleged Respondent

Enter whatever information is known about this person
Name of Alleged Respondent Name of Alleged Respondent First Last
School
Age of Alleged Respondent
Grade of Alleged Respondent
Is this person a student?
Days first respondent absent as a result of the incident (if known):
Information About the Second Alleged Respondent

Enter whatever information is known about this person
Name of Alleged Respondent Name of Alleged Respondent First Last
Age of Alleged Respondent
School
Grade of Alleged Respondent
Is this person a student?
Days second respondent absent as a result of the incident (if known):
Information About the Third Alleged Respondent

Enter whatever information is known about this person
Name of Alleged Respondent Name of Alleged Respondent First Last
Age of Alleged Respondent
School
Grade of Alleged Respondent
Is this person a student?
Days third respondent absent as a result of the incident (if known):
3. Alleged Witness
Name of alleged witness Name of alleged witness First Last
Age of alleged witness
School
Is this person a student?
4. Date(s) Incident(s) Occurred

(At a minimum, the first date is required *)
Date Date / MM / DD YYYY
Date Date / MM / DD YYYY
Date Date / MM / DD YYYY
5. Check the statement(s) that best describes what happened (choose all that apply)

5. Check the statement(s) that best describes what happened (choose all that apply) Any bullying, harassment, or intimidation that involves physical aggression Getting another person to target or demean the student Demeaning behavior to impress others Demeaning behavior just to be mean An act or threat of retaliation Teasing, name-calling, making critical remarks, or threatening, in person or by other means Demeaning and making the student the target of jokes Making rude and/or threatening gestures Excluding or rejecting the student Intimidating, extorting, exploiting the student Spreading harmful rumors or gossip Cyberbullying (social media, text messages, etc.) Gang Related/Gang Recruitment Human Trafficking or Prostitution Recruitment Racial/Ethnic Harassment Sexual Harassment Actions/comments related to the student's race/ethnicity Actions/comments related to the student's national origin Actions/comments related to the student's religion Actions/comments related to the student's sex Actions/comments related to the student's immigration status Actions/comments related to the student's family/parental or marital status Actions/comments related to the student's socio-economic status Actions/comments related to the student's academic performance Actions/comments related to the student's perceived sexual orientation Actions/comments related to the student's gender expression Actions/comments related to the student's gender identity Actions/comments related to the student's disability Actions/comments related to the student's physical appearance Other
6. Where did the incident happen? (check all that apply)

6. Where did the incident happen? (check all that apply) On school property At a school-sponsored activity or event off school property On a school bus On the way to/from school Digital device on school property Digital device off school property During virtual learning Other Location
Other Location
7. Describe the incident(s), including what the alleged respondent(s) said or did.
8. Why do you think the bullying, cyberbullying, harassment, and/or intimidation occurred?
9. Did a physical injury result from this incident?
10. If there was a physical injury, do you think there will be permanent effects?
11. Did a psychological injury result from this incident?
12. Is there any additional information you would like to provide?
Signature Signature First Last
(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.

Bullying, Harassment, or Intimidation Reporting Form

Bullying, Harassment, or Intimidation Reporting Form

DO NOT SUBMIT PERSONALLY IDENTIFIABLE OR OTHER SENSITIVE INFORMATION IN THIS FORM

Person Reporting Incident

The Incident

2. Information About the First Alleged Respondent

Information About the Second Alleged Respondent

Information About the Third Alleged Respondent

3. Alleged Witness

4. Date(s) Incident(s) Occurred

DO NOT SUBMIT PERSONALLY IDENTIFIABLE OR
OTHER SENSITIVE INFORMATION IN THIS FORM