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Bullying Report Form
In order to promote a safe learning environment for all students, the Stewartsville C-2 School District prohibits all forms of bullying. The district also prohibits reprisal or retaliation against any person who reports an act of bullying among or against students. The administrators will investigate the report and take appropriate actions to deal with the situation. Since much of what we do needs to remain confidential, you may not know the steps we take to stop the bullying. If the bullying does not stop, we need to take additional steps. PLEASE LET US KNOW IF THE BULLYING CONTINUES.

In accordance with state law, bullying is defined as intimidation, unwanted aggressive behavior, or harassment that is repetitive or is substantially likely to be repeated and causes a reasonable student to fear for his or her physical safety or property; that substantially interferes with the educational performance, opportunities or benefits of any student without exception; or that substantially disrupts the orderly operation of the school. Bullying includes, but is not limited to: physical actions, including violence, gestures, theft, or property damage; oral, written, or electronic communication, including name-calling, put-downs, extortion, or threats; or threats of reprisal or retaliation for reporting such acts.

Cyberbullying – A form of bullying committed by transmission of a communication including, but not limited to, a message, text, sound or image by means of an electronic device including, but not limited to, a telephone, wireless telephone or other wireless communication device, computer or pager. The district has jurisdiction over cyberbullying that uses the district's technology resources or that originates on district property, at a district activity or on district transportation. Even when cyberbullying does not involve district property, activities or technology resources, the district will impose consequences and discipline for those who engage in cyberbullying if there is a sufficient nexus to the educational environment, the behavior materially and substantially disrupts the educational environment, the communication involves a threat as defined by law, or the district is otherwise allowed by law to address the behavior.
Is it Bullying? Please see the chart and make an appropriate choice. ( You will still see the counselor for any response ) *
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Date *
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YYYY
Your Name
Your answer
Did you witness the Bullying? *
Required
I am a *
Required
Name of person being bullied? *
Your answer
Enter name of Bully and their grade level ( if known) If there was more than one bully, add their names here too. *
Your answer
Select the bullying behavior (select all that apply): *
Required
Description of events (Please be specific-use exact wording, names, dates, location and time etc.) *
Your answer
Why did the bullying happen? *
Your answer
What has been done to help stop the issue? *
Required
Where did this happen? *
Required
If you selected classroom, please identify which room. *
Your answer
Has this behavior happened before? *
Have you reported this event to anyone? *
If yes, who did you report to? *
Your answer
Is there any other information you would like to provide?
Your answer
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