CSMS Bullying Reporting Form
The Buckeye Union School District prohibits bullying in any form on school property, in a school vehicle, at a school sponsored activity or event, or to and from school. Students who have witnessed or been subjected to bullying should immediately report the bullying incident to the appropriate authority which may include any school district staff member including certificated or non-certificated personnel, building administrator or district administrator. If a bullying incident is witnessed by a district staff member, he/she is required to intervene immediately when safe to do so. Once a bullying report has been made to a staff member, appropriate reporting and investigation will ensue. Directions: Complete this form to report alleged bullying. This online form will automatically go to the school site Administrator. An investigation will be conducted to determine further details and a course of action.
The definition of Bullying according to California Ed Code is as follows: Any severe or pervasive physical or verbal act or conduct, including communications made in writing or by means of an electronic act, and including one or more acts committed by a pupil or group of pupils as defined in Section 48900.2, 48900.3, or 48900.4, directed toward one or more pupils that has or can be reasonably predicted to have the effects of placing a reasonable pupil or pupils in fear of harm to that pupil's or those pupil's person or property, causing a reasonably pupil to experience substantial interference with his or her academic performance, or causing a reasonable pupil to experience substantial interference with his or her ability to participate in or benefit from the services, activities or privileges provided by the school.
Date of Alleged Incident(s):
Name of Student Victim:
Grade of Student Victim:
Name of Student Offender(s):
Grade of Student Offender(s):
Where did the incident happen?
(Choose all that apply and please select at least 1)
Off School Property
When did the incident happen?
(Select at least 1)
During class time
I believe that I, or someone I know, has been subjected to bullying in the following form(s):
(Select at least 1)
Physical: Hitting, kicking, spitting, pushing, fighting, tripping
Verbal: Continuous teasing or intimidation, phone calls, abusive language
Psychological/Social: Spreading rumors, manipulating social relationships, promoting social exclusion
Sexual: Includes many of the same behaviors as other categories, but with additions such as exhibitionism, sexual harassment, sexual comments, sexual touching, and sexual gestures
Cyber: Texting/messaging threats, defamatory Web sites, emailing derogatory photos, etc.
Do you believe you are in danger, danger of bodily harm, or in danger of retribution?
Please describe the incident in more detail.
Never submit passwords through Google Forms.
This form was created inside of Buckeye Union School District.