Bullying, Harrassment, or Intimidation Reporting Form
Directions: "Bullying" or "harassment" is any gesture or written, verbal,graphic. or physical act ( including electronically transmitted acts - i.e., cyber bullying, through the use of the Internet, cell phone, personal digital assistant (pda) computer, or wireless handheld device, currently in use or later developed and used by students) that is reasonably perceived as being dehumanizing, intimidating, hostile, humiliating, threatening, or otherwise likely to evoke fear or physical harm or emotional distress and may be motivated either by bias or prejudice based upon any actual or perceived characteristic, such as race, color, religion, ancestry, national origin, gender, sexual orientation,, gender identity or expression; or mental or physical, or sensory disability or impairment; or by any other distinguishing characteristic, or is based upon association with another person who has or is perceived to have any distinguishing characteristic. Bullying and harassment also include forms of retaliation against individuals who report or cooperate in an investigation under this policy. Such behaviors are considered to be bullying or harassment whether they take place on or off school property, at any school-sponsored function, or in a school vehicle or at any time ot place where a child's imminent safety or over-all well-being may be at issue.
Today's Date *
MM
/
DD
/
YYYY
School *
Person Reporting Incident
Name
Optional
Telephone
Optional
E-Mail
Optional
Check the appropriate box:
Name of Student Victim *
Name(s) of alleged offender(s) (If Known) *
Grade *
Building (if known) *
On what date did this incident happen? *
MM
/
DD
/
YYYY
Where did the incident happen? *
Choose all that apply.
Required
Check the statement(s) that best describes what happened *
Choose all that apply:
Required
What did the alleged offender(s) say or do? *
Why did the bullying, harassment or intimidation occur? *
Did a physical injury result from this incident? *
Required
If there was a physical injury, do you think there will be permanent effects? *
Required
Was the student victim absent from school as a result of the incident? *
Required
If yes, how many days was the student victim absent from school as a result of the incident?
Did a psychological injury result from this incident? *
Required
Is there any additional information you would like to provide? *
Submit
Never submit passwords through Google Forms.
This form was created inside of Homer Community School District. Report Abuse