Middle School Bullying Incident Form

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We want to ensure the safety and well-being of all students at Blair Oaks R-II School District. We need your help to report when a child is unsafe or there is a potential safety issue at school. Sending in a false report takes time and resources away from helping those who really need it.

This form can be used to report safety threats, including but not limited to, bullying, harassment, fights, drugs, alcohol or weapons at school. Responses may not be monitored continuously, so please call the appropriate building during school hours if you need immediate help (Elementary 573-634-2808, Intermediate 573-635-6864, Middle School 573-634-2053, or High School 573-635-8514). Please refer to board policy (2655) for more information.

Name of student/victim: *

Name of bully: *

Names of witnesses (if any):

Date and time of day that the incident happened: *

YYYY

Time

Where did the incident happen? *

Check all that apply.

Classroom

Hallway

Restroom

Locker Room

Bus

On the way to/from school

Internet

Cell phone

At school-sponsored activity

Cafeteria

Somewhere on school grounds

Required

Which statement best describes what happened? *

Check all that apply.

Teasing, name calling, making critical remarks or threatening, in person or by other means

Excluding or rejecting the student from activities

Told lies or harmful rumors about the student

Making racial comments or jokes about the student

Took or damaged others' possessions

Made rude and/or threatening gestures (imitating)

Getting another person to hit or harm the student

Making comments or jokes about a student's sexuality or gender orientation

Physical contact (such as hitting, kicking, pushing, etc) towards another student

Required

What other comments or statements do you have about the incident? *

Has this incident been reported to anyone? *

Yes

Required

If yes, please include who the incident was reported to.

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