Bullying Incident Report
Bullying means a single significant act or a pattern of acts by one or more students directed at another student that exploits an imbalance of power and involves engaging in written or verbal expression, expression through electronic means, or physical conduct that occurs within or outside of school property that:

1. Has the effect or will have the effect of physically harming a student, damaging a student’s property, or placing a student in reasonable fear of harm to the student’s property;
2. Is sufficiently severe, persistent, and pervasive enough that the action or threat creates an intimidating, threatening, or abusive educational environment for a student;
3. Substantially disrupts the educational process or the orderly operation of a classroom or school based activities.
4. Includes cyberbullying.


This form may remain anonymous. Students may also use this form to report a bullying incident. An administrator will respond to reports submitted within 3 business days. Please send any additional evidence (i.e. screenshots, photos, etc.) to kim.brooks@mountsacredheart.com
Date of incident *
MM
/
DD
/
YYYY
Time of incident *
Time
:
Location of incident *
Target Name *
Description of incident *
Individuals involved *
Were you a witness to the hurtful behavior? *
Additional information
Your name
Your email address
Your phone number
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