JCCHS Bullying Incident Report

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Bullying, harassment, or intimidation are serious acts and will not be tolerated at John Carroll. This is a form to report alleged bullying, harassment, or intimidation that occurred on school property; at a school-sponsored activity or an event off school property; or on the way to and/or from school, in the current school year. If you wish to report an incident of alleged bullying, harassment, or intimidation, please complete this form with as much detail as possible. Contact the school for additional information or assistance at any time.

Name: *

Telephone:

E-mail: *

Name of student victim:

Name(s) of alleged offender(s) (if known):

Where did the incident occur? (Choose all that apply.)

on school property

at a school sponsored activity or event off school property

Other:

Please describe what happened (Choose all that apply.)

Any bullying, harassment, or intimidation that involves physical aggression

Getting another person to hit or harm the student

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

Demeaning and making the victim of jokes

Making rude and/or threatening gestures

Excluding or rejecting the student

Making racial comments or slurs

Spreading harmful rumors or gossip

Electronic communication

Other:

What did the alleged offender(s) say or do?

Do you have any information to share about why the bullying, harassment or intimidation occurred?

Is there any additional information you would like to provide?

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