Bullying/Harassment Incident Reporting Form
Elm Middle School is committed to providing all students and staff with a safe and civil environment in which all members of the school community are treated with dignity and respect. Bullying/harassment is any electronic, written, verbal, or physical act toward a person based on any actual or perceived trait or characteristic of the person and which creates a hostile school environment that meets one or more of the following conditions:
- Places the student in reasonable fear of harm.
- Has a substantially detrimental effect on the student's physical or mental health.
- Has the effect of substantially interfering with a student's academic performance.
- Has the effect of substantially interfering with the student's ability to participate in or benefit from the services, activities, or privileges provided by a school.
- The situation is not a conflict, which is a fight, battle, or struggle between two students with equal power.

Note* This form will be checked during school hours, not on weekends or holidays.

Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Required
What grade are you in? *
Required
What grade(s) are the students doing the bullying in?
Check all that apply
Name of the student(s) who were doing the bullying.
If you do not know their names, please include descriptors such as advisory teacher, first name only, gender, etc.
Your answer
Name of the student(s) who were being bullied. *
If you do not know their names, please include descriptors such as advisory teacher, first name only, gender, etc.
Your answer
Description of the incident *
Your answer
Who have you reported this incident to? *
Choose all that apply:
Required
How many witnesses were there? *
If you know witnesses names, list them below.
Your answer
Do you have screenshots, pictures or other documentation of this incident?
Name
We take bullying very seriously and will investigate each incident. If you wish to remain anonymous, leave this question blank. If you wish to help with the situation, please place your first and last name on the line and we will follow up with you. Furthermore, if this is an emergency situation, please additionally report this situation to a parent or the police immediately.
Your answer
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