K-6 Bullying Form
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 school's handbook, “Bullying” means intimidating, threatening, abusive, or harming conduct that is objectively offensive and:
1. 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
2. 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 and submit this form. It will, according to MN state law, be investigated within three school days.
Thank you for helping to keep our school safe!
* indicates questions that require an answer
You are a
Your Name (optional)
Please note: anonymous reports may be more difficult to investigate and/or substantiate.
Date and Time of Incident
example 1/20/17 9:15 am
Location of Incident
Bus, Playground etc
Person or Persons doing the bullying
Name and grade of the person who was the victim
(provide the grade if you know - if not ok to omit)
How did you learn about the alleged bullying incident?
Describe what took place, such as the type of bullying (verbal, physical, written, online, etc.), or any other important information
Name/Names of anyone else who witnessed the incident
This report is filed on my honest belief that __________ has bullied or was violent to another person or myself. I certify this information is true and complete to the best of my knowledge *
By clicking submit below, I confirm this statement.
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This form was created inside of Rush City School District #139.