Report Bullying Form

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Definition of Bullying or Peer Intimidation: Is defined as any act or behavior that is occurring frequently in order to hurt another person in any way. Bullying or intimidation is characterized by an individual behaving in a certain way to gain power over another person (Besag, 1989). Behaviors may include name calling, verbal or written abuse, exclusion from activities, exclusion from social situations, physical abuse, or coercion.

BUILDING PRINCIPALS WILL LOOK INTO INCIDENTS ONLY WHEN THE NAME OF THE PERSON REPORTING THE INCIDENT AND THE NAME OF THE ACCUSED BULLY IS GIVEN. Actions taken to resolve the incident are at the building principal's discretion.

Name of person reporting the incident:

Grade of Person Being Bullied

Date and Time of the Incident: *

Name of the Person Bullying Others *

Type of Bullying: *

Check all that apply

Physical (Example: Hitting, Spitting, Kicking, Pushing)

Emotional (Example: Social Exclusion, Spreading Gossip, Intimidation)

Verbal (Example:Threats, Name Calling, Gossiping, Taunting, Teasing)

Sexual (Example: Sexual Remarks or Gestures, Innuendos or Gender Related Comments)

Cyber (Example: Text, Chats, E-mail, Facebook, Twitter)

Racial (Example: Racial slurs, Jokes, Innuendos, or Comments)

Other:

Required

Where did the incident happen? *

Description of the Incident: *

Be sure to include the name of affected parties and the accused bully.

Frequency of bullying incident: *

Name of a contact person or witness *

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This form was created inside of Oakland-Craig Public Schools. Report Abuse

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