Sleepy Eye Elementary Bullying Report Form
General Statement of Policy Prohibiting Bullying
Sleepy Eye Public Schools maintains a firm policy prohibiting bullying conduct that interferes with a student's ability to learn and/or a teacher's ability to educate students. Bullying or cyberbullying by a student against another student is strictly prohibited and will not be tolerated.
Date of alleged incident
Name of student(s) who engaged in bullying
Where did the alleged incident(s) occur?
List any witnesses that were present:
Describe what happened as clearly as possible, including details such as what was said and who made the statements, whether anyone made a threat or demand for something and what threat or demand was made, whether physical contact happened (i.e.: hitting, punching, throwing an item, etc.), whether anyone was injured or property was damaged, the ages or grades of the students, if known, etc.
Check each that apply if the bullying was directed at another student due to the student's actual or perceived:
Gender Identity and Expression
Academic Status Related to Student Performance
Status with Regard to Public Assistance
Was the bullying conduct in retaliation for a student's conduct and if yes, please describe.
Did the bullying occur through an electronic communication (i..e.: Facebook, Twitter, email, etc.) and if so, identify the form of communication? (If available, attach a copy of the communication.)
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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