CBMS Student Harassment & Bullying Complaint Form
The Alabama State Department of Education requires each school system to establish a procedure for the investigation of all incidents reported to school officials of harassment, violence, threats of violence, or intimidation by any other student. This form will assist teachers and staff at Central Baldwin Middle School in investigating these reported incidents of such behavior.
PERSON REPORTING INCIDENT
INFORMATION REGARDING INCIDENT
Name of alleged student victim
Name(s) of alleged offender(s), if known:
Is the alleged offender(s) a student at CBMS?
Name(s) of alleged witness(es), if known:
On what date(s) did the incident happen?
Where did the incident happen? (Please choose all that apply).
On school property
At a school-sponsored activity or event off school property
On a school bus
On the way to/from school property
Via Internet-sent on school property
Via Internet-sent off school property
Select the statement(s) that best describes what happened. (Please choose all that apply).
Any bullying, harassment, or intimidation that involves physical aggression
Hitting, kicking, shoving, spitting, hair pulling, or throwing something
Getting another person to hit or harm the student
Teasing, name-calling, making critical remarks, or threatening, in person or by other means
Making rude and/or threatening gestures
Intimidating (bullying), extorting, or exploiting
Spreading harmful rumors or gossip
Cyberbullying (e.g., social media including Facebook, Twitter, Snapchat, Instagram, Kik, etc.)
Related to the student's perceived sexual orientation
Excluding or rejecting the student
Related to the student's disability
Electronic communication (e.g., e-mail, text, sexting, etc.)
Describe the incident(s), including what the alleged offender(s) said or did
Did a physical injury result from this incident?
Yes, but it did not require medical attention
Yes, and it required medical attention
Is there any additional information that you would like to provide?
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