Bullying Report Form
Bullying is defined as "a single significant act or a pattern of acts by one or more students directed at another student that exploits an imbalance of power and involves engaging in written or verbal expression, expression through electronic means, or physical conduct, has the effect or will have the effect of physically harming a student, causing a student to experience substantial negative mental health effects, damaging a student ’s property, or placing a student in reasonable fear of harm to the student ’s person or of damage to the student ’s property, is sufficiently severe, persistent, and pervasive enough that the action or threat creates an intimidating, threatening, or abusive educational environment for a student, materially and substantially disrupts the educational process or the orderly operation of a classroom or school; or infringes on the rights of the victim at school; and includes cyberbullying."

"Cyberbullying" means bullying that is done through the use of electronic communication, including through the use of a cellular or other type of telephone, a computer, a pager, a camera, electronic mail, instant messaging, text messaging, a social media application, Internet website, or other Internet-based communication tool.

I am a: *
During this incident I was a: *
What is your name? (optional)
Your answer
What is the name of the student you would like to report? *
Your answer
If you do not know the name of the student, please describe the person.
Your answer
Where did this incident take place? *
Required
When did this incident occur? *
Required
If this happened/is happening during school, please give a specific time frame (example class period).
Your answer
Please describe the incident. *
Your answer
Were there witnesses to this incident? *
What are the names of the witnesses? (optional)
Your answer
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) *
Your answer
Did this or other incidents make you feel like harming yourself or others?
Would you like to speak with a counselor? If yes, please add your name. *
What else would you like for us to know about this incident? *
Your answer
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