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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 )
Did you witness the Bullying?
I am a
Member of the Community
Name of person being bullied?
Enter name of Bully and their grade level ( if known) If there was more than one bully, add their names here too.
Select the bullying behavior (select all that apply):
Excluding or rejecting
Making the Victim of Jokes
Racial, Sexual, Religious, or Disability
Teasing/ Name Calling
Related to perceived sexual orientation
Description of events (Please be specific-use exact wording, names, dates, location and time etc.)
Why did the bullying happen?
What has been done to help stop the issue?
Told the person to stop
Moved away from the person
Ignored the situation or did nothing
Tried to make a joke of it; laughed it off
Tried to talk to the person
Told an Adult
Where did this happen?
classroom (see below)
At a school-sponsored activity or event off school property
On a school bus
On the way to/from school
Electronically (text, social media, e.g.)
In the Hallway
If you selected classroom, please identify which room.
Has this behavior happened before?
Have you reported this event to anyone?
If yes, who did you report to?
Is there any other information you would like to provide?
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This form was created inside of STEWARTSVILLE C-2 SCHOOL DISTR.