IC Imagine Bullying Report Form 2017-2018
IC Imagine strives to foster a climate of respect and personal responsibility among students, and does not tolerate bullying in any form. Anyone with knowledge of a situation involving bullying can either report the incident to school officials, or by completing the online form below.

All calls or completed forms will be addressed by IC Imagine administrators or the counseling department. Thank you for your concern and assistance in providing our Champions with a positive learning experience. Please understand that a report does not always result in disciplinary action, but will always be addressed.

Is it Bullying or Conflict? Listed below are the elements that make up a bullying situation.

1. Intent to harm
2. Imbalance of Power
- Including race, color, religion, ancestry, national origin, gender, age, socioeconomic status, academic status, gender identity, physical appearance, sexual orientation, pregnancy, physical development or sensory disability or by association with a person who is perceived to have one or more differences.
3. Repeated over a period of time (or one time and extremely severe.)

Who is reporting
Name of person reporting (optional)
Your answer
If you are not a student at this campus and would like someone to contact you, please add your phone number here. (Optional)
Your answer
Where did the incident occur? Check all that apply.
Required
Has this happened more than once?
Type?
When did it happen?
MM
/
DD
/
YYYY
What time did it happen?
Time
:
Who was bullying, harassing, intimidating or causing harm? * Include first name, last name and grade if known
Your answer
Who was the person being harmed, bullied, harassed or intimidated? * Include first name, last name and grade if known
Your answer
Were there any witnesses? Please list their names here.
Your answer
Describe what happened. Give as much information as you can.
Your answer
Has there been anything that you have done in the past to address this issue? If so, please explain.
Your answer
Submit
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