Bullying Report Form - PreK-2
"Harassment, intimidation or bullying" means any gesture, any written, verbal or physical act, or any electronic communication, whether it be a single incident or a series of incidents, that is reasonably perceived as being motivated either by any actual or perceived characteristic, such as race, color, religion, ancestry, national origin, gender, sexual orientation, gender identity and expression, or a mental, physical or sensory [handicap] disability, or by any other distinguishing characteristic, that takes place on school property, at any school-sponsored function [or], on a school bus, or off school grounds as provided for in section 16 of P.L.2010, CHAPTER 122, that substantially disrupts or interferes with the orderly operation of the school or the rights of other students and that:

a) a reasonable person should know, under the circumstances, will have the effect of physically or emotionally harming a student or damaging the student's property, or placing a student in reasonable fear of physical or emotional harm to his person or damage to his property;

b) has the effect of insulting or demeaning any student or group of students [in such a way as to cause substantial disruption in, or substantial interference with, the orderly operation of the school]; or

c) creates a hostile educational environment for the student by interfering with a student’s education or by severely or pervasively causing physical or emotional harm to the student.
I am a: *
During this incident I was a: *
What is your name? (optional)
What grade are you in? (optional)
Clear selection
What is the name of the student you would like to report? *
Is the student you are reporting the alleged victim or alleged aggressor?
Clear selection
If you do not know the name of the student, please describe the person - or details of what you know about the person
Have you spoken to anyone else about this? Who?
Where did this incident take place? *
When did this incident occur? *
If this happened/is happening during school, please give a specific time frame (example class period)
Date and Time of Incident
Please describe the incident *
Were there witnesses to this incident? *
What are the names of the witnesses? (Optional)
Please rate the severity of this incident from your perspective, 1 being minor incident but unacceptable to 5 being major incident, could result in retaliation or violence. *
Minor but unacceptable
Major incident
Please describe the frequency with which this type of incident occurs. *
One time incident
Every day
How do you feel about this incident or person? (Examples: they are annoying, I hate them, I want to hurt them, they don’t make me mad I just want it to stop…etc) *
Did this or other incidents make you feel like harming yourself or others? If Yes, please discuss with a trusted adult.
Clear selection
What else would you like for us to know about this incident? *
Would you like to speak with a counselor? If yes, please add your name in the section above. *
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