Wilmot Elementary School Bullying/Incident Report Form
Our goal is to make Wilmot Elementary School a bully free zone every day.

Bullying is any severe or repeated physical or verbal act or conduct, including communications made in writing or electronically, directed towards a student or students that has or can be reasonably predicted to have the effect of one or more of the following:

-Placing the student or students in reasonable fear of harm to the student’s or students’ person or property;

-Causing a substantially detrimental effect on the student’s or students’ physical or mental health;

-Substantially interfering with the student’s or students’ academic performance; or

-Substantially interfering with the student’s or students’ ability to participate in or benefit from the services, activities, or privileges provided by a school.

It may include, but is not limited to, actions such as verbal taunts, physical aggression, exclusion from peer groups within school, name-calling, or harassment and intimidation. Wilmot Elementary School prohibits all forms of bullying behavior on school property, in school buses, at school-sponsored events, or during travel to and from school. Any violation of this policy shall be subject to discipline.
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Who is the target of the behavior? *
If you are the target, please state your name.
Who is/are the student(s) engaging in the behavior? *
Please describe the incident. Try to include who, what, where, when, and why. *
Where did this incident take place? *
Check all that apply
Required
Was the incident based on any of the following characteristics? *
Check all that apply
Required
Do you think this is bullying behavior? *
Keep in mind bullying is considered any severe or repeated physical or verbal act or conduct.
Has this happened before with this student or is this an isolated (one-time) incident? *
If this has happened before, when did this occur? *
Have you talked to any adults about this incident before reporting what happened using this form? If so, which adult did you speak with and when did you report the incident? *
(Name and Date needed)
You can either choose to remain anonymous or submit your name confidentially so one of your school administrators can discreetly find time to meet with you to discuss it further. Understand that submitting your name anonymously means that it becomes difficult to address your concern beyond making the administrative team aware of your concern. Please submit your name or type Anonymous. *
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