Harassment, Intimidation and Bullying Report
Definition of bullying: an overt, unwanted, repeated act or gesture, including written or verbal communications or images transmitted in any manner, physical acts, or any other behaviors that are committed by a student or group of students against another student with the intent to harass, ridicule, humiliate, intimidate, or harm the other targeted student and create for the targeted student an objectively hostile school environment.
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First Name:
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Last Name:
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E-Mail:
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Phone #:
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Address:
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City:
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State:
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Zipcode:
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Incident Information
When did this incident happen? *
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Location of Incident: *
Additional Location Information:
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Your Role: *
Please enter any other information about how you were involved or how you know of this incident. *
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Types of harrassment, intimidation, bullying or harm
Physical involves hurting a person’s body or possessions. Physical includes:
- Hitting/kicking/pinching
- Spitting
- Tripping/pushing
- Taking or breaking someone’s things
- Making mean or rude hand gestures
Verbal is saying or writing mean things. Verbal includes:
- Teasing
- Name-calling
- Inappropriate sexual comments
- Taunting
- Threatening to cause harm
Social, sometimes referred to as relational, involves hurting someone’s reputation or relationships. Social includes:
- Leaving someone out on purpose
- Telling other children not to be friends with someone
- Spreading rumors about someone
- Embarrassing someone in public
Cyberbullying is bullying that takes place using electronic technology. Examples of cyberbullying include:
- Mean text messages or emails
- Rumors sent by email or posted on social networking sites
- Embarrassing pictures, videos, websites, or fake profiles
Please enter as much information as possible about the type of bullying your are reporting.
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Cause of harassment, intimidation, bullying or harm: *
Method of harassment, intimidation, bullying or harm: *
What is the victims age/or grade?
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Who was the person being harassed, intimidated bullied or harmed? (victims names if you have them)
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What is the offenders age/or grade?
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Who was harassing, intimidating, bullying or causing harm? *
Who was harassing, intimidating, bullying or causing harm? (bullies names if you have them)
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Description: (please give us as much information as you can about the incident.) *
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