Bullying/Harassment Incident Report Form
Surry County Public Schools


“Bullying” is the systematic and chronic inflicting of physical hurt or psychological distress on another person. The Code of Virginia at §221.267.01 defines bullying as any aggressive and unwanted behavior that is intended to harm, intimidate, or humiliate the victim; involves a real or perceived power imbalance between the aggressor or aggressors and victim; and is repeated over time or causes severe emotional trauma. “Bullying” includes cyber bullying. “Bullying” does not include ordinary teasing, argument, or peer conflict.

“Harassment” is any behavior that is disturbing and threatening. Sexual harassment is a type of harassment that is sexual in nature; unwelcome and denies or limits a student’s ability to participate in or benefit from a school’s education program. Sexual harassment can be carried out by school employees, other students, and third parties/non-employees. Both male and female students can be victims of sexual harassment, and the harasser and the victim can be of the same sex.

Name of Reporter/Person Filing the Report
(Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.) You can telephone our Hotline at (757) 267-9015 to report suspected bullying, harassment or sexual harassment. You can also report suspected bullying, harassment or sexual harassment to teachers, guidance counselors, or principals. Finally, if you would like to report sexual harassment you can report it to our Title IX Compliance Officers: Dr. Serbrenia J. Sims, Assistant Superintendent, or Mr. Giron Wooden, Principal.
Are you the target of bullying/harassment/sexual harassment?
Please select the following that apply. I am a _____________________.
Your contact information/telephone number:
If student, what school do you attend?
If student, what grade are you in?
If staff member, name of your school or work site:
Information about the Incident:
Name of victim/target (of aggression):
Name of aggressor (Person who started the aggression):
Date(s) of Incident(s):
Time when incident(s) occurred:
Location of incident(s) (Be as specific as possible):
Witnesses (List people who saw the incident or have information about it):
Describe the details of the incident (people involved, what occurred, and what each person did and said, including specific words used).
Name of Person filing out this report
You can notify any teacher or administrator about bullying/harassment/sexual harassment incidents or you can return this report to the Guidance Office. You can also use our Hotline at (757) 267-9015 to make a verbal report.
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