Bullying & Sexual Harassment &/or Assault Report Form
Pease complete the following form should you suspect a student is being bullied. As a reminder, in the District of Columbia, bullying is defined under the Youth Bullying Prevention Act of 2012 as any severe, pervasive or persistent act of conduct that can be reasonable predicted to: (a) Place the youth in reasonable fear of physical harm to their person or property; (b) Cause a substantial detrimental effect on the youth's physical or mental health; (c) Substantially interfere with the youth's academic performance or attendance or; (d) Substantially interfere with the youth's ability to participate in or benefit from the services, activities, or privileges provided by an agency, educational institution or grantee.

Please complete the following form should you suspect a student is experiencing sexual harassment or assault. CMI defines “sexual harassment” as unwelcome sexual advances, requests for sexual favors, and/or other inappropriate verbal, written, or physical conduct of a sexual nature, that has the effect of unreasonably interfering with a student’s work and/or academic performance; or creating an intimidating, hostile learning environment. CMI defines “sexual assault” as any form of sexual penetration or forced sexual acts.

Name of reporter
Your answer
Check whether you are:
Check whether you are a:
Your contact information/telephone number
Your answer
Type of Behavior Reporting
Name of the Target
Your answer
Name of Aggressor (person who engaged in the behavior)
Your answer
Date(s) of Incident(s)
Your answer
Time when incident(s) occurred
Location of incident(s) (be as specific as possible)
Your answer
Witnesses (List people who saw the incident or have information about it)
Your answer
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).
Your answer
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