RPA Bullying Behavior Report Form-C

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This form should be completed to report potential bullying by others to RPA counselors and administration.
(This may include alleged bullying behavior, harassment, discrimination, or cyber-related incidents.)

If you need to report a possible bullying situation for a student that does not attend RPA please use the following link from Positive Youth Development:

https://bit.ly/2UQH9eh

BULLYING DEFINITION

Bullying is unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time. Both (students) who are bullied and who bully others may have serious, lasting problems.

CONFIDENTIAL! We will NOT share the person's name who made this report, but we will work with staff to stop the bullying.

REPORTING PERSON

Name (optional)

Telephone Number (optional)

Email address (optional)

I am (check one) *

Parent

Student

I am (check one) *

Person who is getting bullied

Person who witnessed bullying

Person who is concerned about bullying

BULLYING BEHAVIORS

Date of incident (if known)

YYYY

Describe what happened (be very specific) *

Please check the box that best describes what the bullying behaviors look like. Choose all that apply. *

Physical: Hitting, kicking, shoving, spitting, etc.

Getting another person to harm the student in any way

Teasing, name calling, put downs, criticizing, jokes

Threatening (in person, by email, by phone, text message, etc.)

Spreading harmful rumors or gossip

Demanding money, homework, personal items, etc.

Cyberbullying: Social media, etc.

Other:

Required

PERSON THE BULLYING INVOLVES

Name of person getting bullied (if multiple people, please include all names) *

Grade Level *

Have you reported the bullying to any other staff members at RPA? *

Yes

If YES, who did you report it to?

Are there any additional questions/comments/concerns that you have and would like to add?

I agree that all of the information on this form is accurate to the best of my knowledge. *

I agree

Thank you for completing this form. Each complaint of bullying will be promptly investigated to determine how we can help to change the situation. (Education Code 234.1)

Would you like us to contact you? (If YES, please make sure to include contact information at the top of this form). *

Yes

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