Bullying Incident Reporting Form
Bullying includes cyber-bullying and means any severe or pervasive physical or verbal act or conduct, including communications made in writing or electronically, directed toward a student or students that has or can be reasonably predicted to have the effect of one or more of the following:
1. Placing the student or students in reasonable fear of harm to the student’s or students’ person or property;
2. Causing a substantially detrimental effect on the student’s or students’ physical or mental health;
3. Substantially interfering with the student’s or students’ academic performance; or
4. Substantially interfering with the student’s or students’ ability to participate in or benefit from the services, activities, or privileges provided by a school.

Cyber-bullying means bullying through the use of technology or any electronic communication, including without limitation any transfer of signs, signals, writing, images, sounds, data, or intelligence of any nature transmitted in whole or in part by a wire, radio, electromagnetic system, photo-electronic system, or photo-optical system, including without limitation electronic mail, Internet communications, instant messages, or facsimile communications. Cyber-bullying includes the creation of a webpage or weblog in which the creator assumes the identity of another person or the knowing impersonation of another person as the author of posted content or messages if the creation or impersonation creates any of the effects enumerated in the definition of bullying. Cyber-bullying also includes the distribution by electronic means of a communication to more than one person or the posting of material on an electronic medium that may be accessed by one or more persons if the distribution or posting creates any of the effects enumerated in the definition of bullying.

District 113A’s procedures for handling alleged incidents of bullying follow:

1. Any student, staff, member, or parent of the District 113A community who believes there has been harassment, intimidation or bullying may report the incident to the Principal or designee using the Bullying Incident Reporting form available in the building offices and on the district website.
2. Reports may be made anonymously and all reports will be investigated.
3. Retaliation against any person who reports an act of bullying is prohibited.
4. A student will not be punished for reporting; however, knowingly making a false accusation is considered an act of bullying, and will be investigated.
5. Consequences and/or restorative measures shall be determined by the Principal or designee.
6. The Principal or designee will maintain a record of each investigation regarding allegations of bullying.

Are you: *
Please identify your role. *
Where did this alleged incident occur? *
Date of incident *
MM
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YYYY
Time of incident *
Time
:
Name of person being bullied *
Your answer
Name of person engaged in bullying behavior, if known; if not known, please indicate that. *
Your answer
Name of witnesses (people who saw incident or may have information about it) *
Your answer
Type of bullying *
Required
Describe the details of the incident (including names of people involved, what occurred and what each person did and said, including specific words used.) *
Your answer
Was this incident reported:
Are you aware of other times similar incidents have occurred with the same people?
Name of person filing report (can be anonymous)
Your answer
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