Holdingford Elementary Bullying Incident Report
The person REPORTING the bullying incident has the option of including his or her name on this form OR submitting the form anonymously. Anonymous reports are more difficult to investigate. According to our School Board policy as found in our student handbook, "Bullying" means intimidating, threatening, abusive, or harming conduct that is objectively offensive and:

a) an actual or perceived imbalance of power exists between the student engaging in the prohibited conduct and the target of the prohibited conduct, and the conduct is repeated or forms a pattern;
or
b) materially and substantially interferes with a student's educational opportunities or performance or ability to participate in school functions or activities or receive school benefits, services, or privileges.

Please answer all sections that apply. It will, according to MN state law, be investigated within three school days.

Thank you for helping to keep our school safe!

Name of reporter/person filing the report:
Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.
Your answer
This report should be sent to...
Are you the... *
Select one from the box below
Are you a *
Student, Parent, Staff Member or Other. Please specify...
Your answer
Your contact information/telephone number:
Your answer
Name of Target (of the behavior): *
Your answer
Name of Aggressor (Person who engaged in the behavior): *
Your answer
List of the bullying behaviors. *
Your answer
CyberBullying Behavior: *
Mark all that apply.
Date and Time of Incident: *
MM
/
DD
/
YYYY
Time
:
Location of Incident (Be as specific as possible): *
Your answer
Witnesses (List people who saw the incident or have information about it): *
Please include if the witness(es) is a student, staff member, or other
Your answer
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words and actions used). *
Your answer
This report is filed on my honest belief that the aggressor named above has bullied or was violent to another person or me. I certify this information is true and complete to the best of my knowledge. *
By selecting "I agree" and submitting this form you validate that the statement above is true and correct.
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