Harassment, Intimidation, Bullying, and Cyberbullying Behavior Checklist
Directions: In accordance with the provisions of Act 755 of the 2010 Legislative Session, this form is to be used to document the details of each reported incident of harassment, intimidation, and bullying that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; or on the way to and/or from school. It also is to be used to address cyber bullying .
What is bullying?
Please watch the video below before you fill out the following form.
Date of incident
MM
/
DD
/
YYYY
Time
:
Incident Number *
Your answer
Are you the victim or a witness? *
What is your last name? *
Your answer
What is your first name? *
Your answer
Name(s) of alleged perpetrator(s) *
Your answer
Indicate type of incident. *
Check all items below that apply: *
Required
Where did the incident happen? *
Be descriptive.
Your answer
Were there any witnesses?
If there were witnesses please provide names separated with commas.
Example: John Doe, Jane Doe
Your answer
Do you have any Physical evidence? Describe. *
Notes, E-Mail, Video
Your answer
If you feel the incident was in any way motivated by any of the following please indicate by checking where appropriate.
Please describe the incident along with any relevant information that you would like to provide.
Your answer
Have you reported this incident to anyone else? *
Parent, counselor, teacher etc.
Your answer
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