Bullying Complaint Form
Directions: Bullying, harassment, and intimidation are serious and will not be tolerated. This is a form to report alleged bullying harassment, or intimidation that occurred during the current school year on school property, at a school-sponsored activity or event off school property, on a school bus, on the way to and/or from school*, or on the internet-sent on or off school property; or that substantially disrupted the orderly operation of the school. Bullying, harassment and intimidation includes any intentional conduct, including verbal, physical or written conduct, or an intentional electronic communication, that creates a hostile educational environment by substantially interfering with a student's educational benefits, opportunities or performance, or with a student's physical or psychological well-being. (Definitions for Bullying, Cyberbullying, Harassment, and Intimidation are provided below.)
Bullying - A pattern or behavior when a person repeatedly uses power in an intentional manner, including verbal, physical, or written conduct or intentional electronic communication against one or more students.
Cyberbullying - The use of electronic communication to harm or harass others in a deliberate, repeated, and hostile manner.
Harassment - Includes actual or perceived negative actions that offend, ridicule, or demean another individual with regard to race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, physical or mental ability, or disability.
Intimidation - subjecting an individual to intentional action that seriously threatens and induces a sense of fear and/or inferiority.
Conduct that is of a sexual nature is generally thought to mean actions, language, or visual materials which specifically refer to, portray, or involve sexual activity or language. Conduct of a sexual nature may include overt sexual solicitations, inappropriate touching, sexual jokes, and inquiries about a person's sex life. Sexual harassment is the broader term that encompasses conduct of a sexual nature such as unwelcome sexual advances, requests for sexual favors, and other verbal or physical contact of a sexual nature. Sexual harassment also includes acts that are not overtly sexual but rather are directed at individuals based on their gender such as profanity or rude behavior that is gender-specific.
If you are a student, the parent/guardian of a student, a close adult relative of a student, or a school staff member and wish to report an incident of alleged bullying harassment, or intimidation, complete this form and submit it. Submitted forms will be emailed to the Principal at the student victim's school. You may contact the school for additional information or assistance at any time.
Name of Complainant:
Name of alleged victim(s):
Name of alleged perpetrator(s):
Name of witness(es):
Date of complaint:
Select the statement(s) that best describes what happened (choose all that apply):
Any bullying, harassment, or intimidation that involves physical aggression
Getting another person to hit or harm the student
Teasing, name-calling, making critical remarks, or threatening, in person or by other means
Demeaning and making the victim of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Intimidating, extorting, or exploiting
Spreading harmful rumors or gossip
Related to the student's disability
Related to the student's perceived sexual orientation
Cyber bullying (e.g. social media including Facebook, Twitter, Snapchat, Instagram, etc.)
Electronic Communication (e.g. email, text, sexting, etc.)
Human trafficking/Prostitution recruitment
Sexual in nature
Where did the incident happen (choose all that apply)?
On school property
Internet - sent on school property
At a school-sponsored activity or event off school property
On the way to/from school*
Via Internet - sent off school property
Describe the incident(s), including what the alleged offender(s) said or did.
Did a physical injury result from this incident?
Is there any additional information you would like to provide?
Never submit passwords through Google Forms.
This form was created inside of PSASB INC.