Harrassment, Intimidation, or Bullying Form

Directions: Harrassment, intimidation, or bullying are serious and will not be tolerated. This is a form to report alleged harrassment, intimidation, or bullying that occurred on school property; at a school-sponsored activity or event off school property; on a bus; or on the way to and/or from school*, in the current school year. If you are a student victim, the parent/guardian of a student victim, a clost adult relative of a student victim, or a school staff member and wish to report an incident of alleged harassment, intimidation, or bullying, complete this form. Contact the school for additional information or assistance at any time.

Harrassment, intimidation, or bullying means intentional conduct, including verbal, physical, or written conduct, or an intentional electronic communication, that (1) creates a hostile educational environment by substantially interfering with a student's educational benefits, opportunities, or performance, or with a student's physical or psychological well-being, and is 1. motivated by an actual or a perceived personal characteristic including race, national origin, martial status, sex, sexual orientation, gender identity, religion, ancestry, physical attribute, socioecomonic status, familial status or physical or mental ability or disability; 2. threatening or seriously intimidating; and (ii) 1. Occurs on school property, at a school event, or on a school bus; or 2. substantially disrupts the orderly operation of a school. Electronic communication means a communication transmitted by means of an electronic device, including a telephone, cellular phone, computer or pager.

Todays date: *
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School:
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School System:
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Person Reporting Incident
Name:
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Telephone Number
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Email Address:
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Please check the appropriate box:
Student Information
Name of Student Victim:
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Age of Student Victim:
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Name, Age & School of Alleged Offender(s) (if known):
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On what dates did the incident happen?
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What statement best describes what happened?
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If you chose electronic communication or Other in the previous question, please specify:
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Where did the incident happen?
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What did the alleged offender(s) say or do?
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Why did the harassment, intimidation or bullying occur?
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Did a physical injury result from this incident?
If there was a physical injury, do you think there will be permanent effects?
Was the student victim absent from school as a result of this incident?
How many days was the student victim absent from school as a result of this incident?
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Did a psychological injury result from this incident?
Is there additional information that you would like to provide?
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