Bullying Reporting Form

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BULLYING, HARASSMENT OR INTIMIDATION REPORTING FORM

Bullying, harassment, and intimidation are serious and will not be tolerated. Please complete this form to report alleged bullying, harassment, or intimidation that occurred during the current school year on school property, on a school bus, or on the way to and/or from school, or on the internet-sent on or off school property; or that substantially disrupted the orderly operation of the school. Bullying, harassment and intimidation includes any intentional conduct, including verbal, physical or written conduct, or an intentional electronic communication, that creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities or performance, or with a student’s physical or psychological well-being.

Definitions of Bullying, Cyber bullying, Harassment, and Intimidation are provided below.

1. Bullying (From PDE) – “BULLYING” SHALL MEAN AN INTENTIONAL ELECTRONIC, WRITTEN, VERBAL OR PHYSICAL ACT, OR A SERIES OF ACTS:
(1) DIRECTED AT ANOTHER STUDENT OR STUDENTS;
(2) WHICH OCCURS IN A SCHOOL SETTING;
(3) THAT IS SEVERE, PERSISTENT OR PERVASIVE; AND
(4) THAT HAS THE EFFECT OF DOING ANY OF THE FOLLOWING:
(I) SUBSTANTIALLY INTERFERING WITH A STUDENT’S EDUCATION;
(II) CREATING A THREATENING ENVIRONMENT; OR
(III) SUBSTANTIALLY DISRUPTING THE ORDERLY OPERATION OF THE SCHOOL; AND “SCHOOL SETTING” SHALL MEAN IN THE SCHOOL, ON SCHOOL GROUNDS, IN SCHOOL VEHICLES, AT A DESIGNATED BUS STOP OR AT ANY ACTIVITY SPONSORED, SUPERVISED OR SANCTIONED BY THE SCHOOL.

2. Cyber bullying – The use of electronic communication to harm or harass others in a deliberate, repeated, and hostile manner.

3. Harassment – Includes actual or perceived negative actions that offend, ridicule, or demean another individual with regard to race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, physical or mental ability, or disability.

4. Intimidation – subjecting an individual to intentional action that seriously threatens and induces a sense of fear and/or inferiority. Conduct that is of a sexual nature is generally thought to mean actions, language or visual materials which specifically refer to, portray or involve sexual activity or language.

Conduct of a sexual nature may include overt sexual solicitations, inappropriate touching, sexual jokes, and inquiries about a person's sex life. Sexual harassment is the broader term that encompasses conduct of a sexual nature such as unwelcomed sexual advances, requests for sexual favors, and other verbal or physical contact of a sexual nature. Sexual harassment also includes acts that are not overtly sexual but rather are directed at individuals based on their gender such as profanity or rude behavior that is gender-specific.

If you are a student, the parent/guardian of a student, a close adult relative of a student, or a school staff member and wish to report an incident of alleged bullying, harassment, or intimidation, complete this form and return it to the principal at the student victim’s school. You may contact the school for additional information or assistance at any time.

Email *

Date you are filing this report *

YYYY

Name of the person filing this report *

Relationship to the victim *

A staff member at Provident Charter School

Family member of the student (Victim)

Student at Provident Charter School

Bystander (Witness)

Name of the alleged student victim that attends Provident Charter School *

Name of the alleged offender(s) that attend Provident Charter School *

Name(s) of alleged offender(s) (if known) who do not attend Provident Charter School and the school they attend if known:

Select all statement(s) that best describes what happened (choose all that apply) *

Any bullying, harassment, or intimidation that involves physical aggression

Getting another person to hit or harm the student

Teasing, name-calling, making critical remarks, or threatening, in person or by other means n 3

Demeaning and making the victim of jokes

Making rude and/or threatening gestures

Excluding or rejecting the student Intimidating, extorting, or exploiting

Spreading harmful rumors or gossip

Related to the student’s disability

Related to the student’s perceived sexual orientation

Cyber bullying (e.g. social media

Electronic communication (e.g. email, text, sexting, etc.)

Gang related

Gang recruitment

Human trafficking/Prostitution recruitment

Racial Harassment

Sexual Harassment

Required

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

On school property

At a school sponsored activity or an activity off school property

Via an electronic device - Sent off school property

Via an electronic device - Sent from school property

On the school bus

On the way to or from school

Required

Describe the alleged incident(s), including what the alleged offender(s) said or did. *

Why did the bullying, harassment or intimidation occur? *

Did a physical injury result from this incident? *

Yes, but it did not require medical attention

Yes, and it required medical attention

Unsure

Was the student victim absent from school as a result of the incident? *

Yes

Unsure

Did a psychological injury result from this incident? *

Yes, but psychological services have not been sought

Yes, and psychological services have been sought

Unsure

Is there any additional information you would like to provide?

Submit

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