Report Bullying, Intimidation, or (Sexual) Harassment

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form has been created to help provide a safe means of reporting an incident of Bullying, Intimidation, and/or (Sexual) Harassment to school personnel. Victims or witnesses are encouraged to report any of the above incidents. Reporters may choose to remain anonymous.

DEFINITIONS

Bullying is the repeated physical or verbal conduct which serves to harass, demean, humiliate, abuse, victimize, deny, or exclude another student from the pursuit of participation in school related activities.

Intimidation is the intentional behavior by a student that places another student in fear of harm of person or property. Intimidation can be manifested emotionally or physically, either directly or indirectly, and by use of social media.

Harassment is the intentional behavior by a student that is disturbing or threatening to another student. Intentional behaviors that characterize harassment include, but are not limited to stalking, hazing, name calling, unwanted physical contact and unwelcome verbal or written comments, photographs and graphics. Harassment may be related, but not limited to, race, religious orientation, sexual orientation, cultural background, economic status, size or personal appearance. Harassing behaviors can be direct or indirect and by use of social media.

Sexual Harassment is unwanted or unwelcome sexual advances, requests for sexual favors, and other verbal or physical contact of a sexual nature that interferes with an individual’s work/school performance or creates an intimidating, hostile, or offensive environment.

Thank you for taking the time to complete this form. WCHS appreciates your help in maintaining a safe environment for our students and staff.
6/2024

Your Name (Optional)

Date *

YYYY

You are a: *

Student

Parent

Staff member

Other

Indicate here if you prefer to remain anonymous. *

YES

Are you the victim of the incident(s) that you are reporting? *

Yes

Date of incident? *

YYYY

Time of incident?

Victims name? *

Name of offender? *

Did you witness the incident? *

Yes

List other witnesses to the incident.

If this is a re-occurring situation, how long has it been going on? *

Was the incident based on any of these characteristics? (Check all that apply.) *

Race

Color

Nationality

Sex

Sexual orientation

Gender identity

Gender-related identity

Gender-related expression

Ancestry

Age

Religion

Physical disability

Mental disability

Order of protection status

Homeless status

Marital status

Parental status

Pregnancy

Associated with person/group with one or more of the above actual or perceived characteristics

I don't know

Other

Required

If you answered the previous question as "Other", please explain.

Student was targeted in the following way: (Check all that apply): *

Electronic devices (e.g., internet, Social media platforms, text, email, cyberbullying,etc.)

Written communication (e.g., handwritten notes, other written documents, email, etc.)

Physical act or conduct (e.g., pushing, hitting, destruction of property, stalking, etc.)

Verbal act or conduct (e.g., rumors, lies, name-calling, using derogatory slurs, etc.)

Social (e.g. purposeful exclusion, causing psychological harm, etc.)

Items depicting implied hatred or prejudice were worn, possessed or displayed

Other

Required

If you answered the previous question as "Other", please explain.

Student was targeted in the following location (check all that apply): *

Classroom

Locker room

Hallway

Extracurricular activity

Cafeteria

Bus

Restroom

Bus stop

Gym

School or related activity or event

Other

Required

If you answered the previous question as "Other", please explain.

Please tell us about the incident in your own words. Use as much detail as possible - what time did the incident(s) take place, who witnessed it, what was said, where did it happen, what types of interactions occurred (physical, written, social, electronic, etc.). *

The above information is true and accurate to the best of my knowledge. False reports may result in disciplinary action. *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Washington Community High School.

Does this form look suspicious? Report

Forms