Sleepy Eye High School Bullying Report Form
ISD 84 maintains a firm policy prohibiting all forms of bullying. All persons are to be treated with respect and dignity. Bullying by any pupil, teacher, administrator or other school personnel who creates an intimidating environment will not be tolerated under any circumstances.
Bullying means any written or verbal expression, physical actor or gesture, or intentional electronic communication by an individual that is intended to cause or is perceived as causing distress to another and which substantially interferes with another’s educational benefits, opportunities, and/or performance on school property, at a school sponsored event or on the bus. Bullying includes, but is not limited to, conduct by an individual or group that a reasonable person under the circumstances knows or should know has the effect of: 1. harming someone, 2. damaging of someone’s property. 3. Placing someone in reasonable fear or harm to person or property. 4. Creating a hostile educational environment. 5. Intimidating someone.
Name of victim:
Name of alleged offender:
Witnesses or Bystanders:
What date(s) did the incident happen?
Have you submitted a bullying report for this issue before?
Where did the incident happen? (Check all that apply)
On school property
On the bus
School sponsored event
On the way to/from school
If the incident happened on school property, where specifically?
Nature of bullying being reported (check all that apply)
Physical: Acts such as hitting, spitting, kicking, or damaging your or another student’s property.
Verbal: Saying mean or hurtful things or threatening you or another student.
Social: Excluding you or a student from a group, telling peers not to talk to you or another student.
Emotional: Spreading rumors or lies about you or another student.
Cyber/Online: Occurs on website or social media, by cell phone, email or text message.
What did the alleged offender(s) say or do?
What resources/tools have you used so far to handle this specific situation? (Check all that apply)
Ignore the person/walk away
Told them to stop
Report to a teacher
Talked with your counselor about the situation
Reported to the principal
I am submitting this form based on my belief that ____________ bullied me or another person. I am reporting this because I am concerned and I want the situation to be better in the future.
By submitting this form I certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge and belief.
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This form was created inside of Sleepy Eye Public Schools.