Minford High School Student Bullying Report Form
Please complete the following form, responding only to the questions that you feel comfortable answering and are able to accurately answer.  Please know that this will only be seen by administrative staff and it is important that they know who the victim is and the district strictly prohibits retaliation against anyone who files a bullying report.

Harassment, intimidation, or bullying, in accordance with Ohio Revised Code, means any intentional written, verbal, graphic or physical acts including electronically transmitted acts i.e., Internet, cell phone, personal digital assistant (PDA), or wireless hand-held device, either overt or covert, by a student or group of students toward other student/school personnel with the intent to harass, intimidate, injure, threaten, ridicule or humiliate.  Such behaviors are prohibited on or immediately adjacent to school grounds, at any school-sponsored activity, on school-provided transportation or at any official school bus stop that a reasonable person under the circumstances should know will have the effect of:

1)  Causing mental or physical harm to the other student/school personnel including placing an individual in reasonable fear of physical harm and/or damaging of students’ personal property; and

2) Is sufficiently severe, persistent, or pervasive that it creates an intimidating, threatening, or abusive educational environment for the other student/school personnel.

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Describe what happened/what is happening: *
When did it happen? *
Required
Where did it happen? *
Select all that apply
Required
Who was committing the bullying? *
If you don't know the bully's name(s), please describe him/her.
Who was the victim of the bullying? *
Please know this is very important in order for us to address the issue.
Did anyone else witness the bullying? *
If yes, please list.
Were you or others physically hurt? *
Please explain
Was there damage to anyone's personal property? *
Required
If you answered yes to the previous question, please explain.
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)? *
Required
Have you told anyone about the bullying? *
Select all that apply
Required
Have you previously filed a bullying report? *
This information is used to determine if retaliation is occurring.
Required
Your Name: *
Your grade and age:
How can we contact you?
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