Rush Springs Public Schools Bullying and Harassment Report

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Revised 1/1/2025

Today's Date *

YYYY

Name of Student Victim *

Grade of student victim *

Name and grade of alleged witness(es) *

Name and grade of alleged offender(s) *

On what date(s) did the incident(s) happen *

Select the statement(s) that best describe what happened? (check all that apply) *

physical agression

getting another person to hit or harm a student

teasing, name-calling, making critical remarks, or thereatening someone, in person or by other means

demeaning the victim

making rude and/or threatening gestures

excluding or rejecting a student

intimidating, extorting or exploiting a student.

spreading harmful rumor or gossip

bullying or harassment related to a student's disability

bullying or harassment related to a student's perceived sexual orientation

cyberbulling (e.g. social media, inlcuding Facebook, Instagram, Snapchat, Tik Tok, X etc)

electronic communication (email or text messages)

gang-related

gang-recruitment

human trafficking/prostitution

racial harassment

sexual harassment

Other:

Required

Where did the incident happen? (check all that apply) *

on school property

on the school bus

at a school-sponsored activity or event off of school property

on the way to/from school

online (via the Internet/cell phone) -- sent on or off school property

Other:

Required

Describe the incident(s), including as much detail as possible. Please include what the alleged offender(s) said or did. *

Any additional information that you would like to provide:

Name of Person Reporting the Incident (OPTIONAL)

Phone Number of Person Reporting the Incident (OPTIONAL)

Email Address of Person Reporting the Incident (OPTIONAL)

Relationship of Person Reporting Incident to Victim

Student/Peer

Parent/Guardian of a Student

Relative of a Student

School Staff

Bystander

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