VVCM Bullying Reporting Form
The Buckeye Union School District prohibits bullying in any form on school property, in a school vehicle, at a school sponsored activity or event, or to and from school. Students who have witnessed or been subjected to bullying should immediately report the bullying incident to the appropriate authority which may include any school district staff member including certificated or non-certificated personnel, building administrator or district administrator. If a bullying incident is witnessed by a district staff member, he/she is required to intervene immediately when safe to do so. Once a bullying report has been made to a staff member, appropriate reporting and investigation will ensue. Directions: Complete this form to report alleged bullying. This online form will automatically go to the school site Administrator. An investigation will be conducted to determine further details and a course of action.
The definition of Bullying according to California Ed Code is as follows: Any severe or pervasive physical or verbal act or conduct, including communications made in writing or by means of an electronic act, and including one or more acts committed by a pupil or group of pupils as defined in Section 48900.2, 48900.3, or 48900.4, directed toward one or more pupils that has or can be reasonably predicted to have the effects of placing a reasonable pupil or pupils in fear of harm to that pupil's or those pupil's person or property, causing a reasonably pupil to experience substantial interference with his or her academic performance, or causing a reasonable pupil to experience substantial interference with his or her ability to participate in or benefit from the services, activities or privileges provided by the school.
* Required
Email address
*
Your email
Date of Alleged Incident(s)
*
MM
/
DD
/
YYYY
Name of Student Victim
*
Your answer
Grade of student victim
Choose
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Unknown
Name of Student Offender (s)
*
Your answer
Grade of student offender
Choose
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Unknown
Where did the incident happen?
*
Classroom
Hallway
Lunch Room
Restroom
Black top/Field
Field trip/activity/event
Off school property
Email/Text/Social Media/Computer
Other:
Required
When did the incident happen?
*
During class time
Passing period
PE
Break/Recess
Before/After School
Lunchtime
School Activity/Event
Other:
Required
I believe that I, or someone I know, has been subjected to bullying in the following form(s)
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Physical: Hitting, kicking, spitting, pushing, fighting, tripping
Verbal: Continuous teasing or intimidation, phone calls, abusive language
Psychological/Social: Spreading rumors, manipulating social relationships, promoting social exclusion
Sexual: Includes many of the same behaviors as other categories, but with additions such as exhibitionism, sexual harassment, sexual comments, sexual touching, and sexual gestures
Cyber: Texting/messaging threats, defamatory Web sites, emailing derogatory photos, et
Required
Do you believe you are in danger, danger of bodily harm, or in danger of retribution?
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Yes
No
Please describe the incident in more detail. *
*
Your answer
Send me a copy of my responses.
Submit
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