WCHS Bullying Report Form

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Washington Community High School is committed to creating a safe, supportive, and positive environment for students to obtain an education. School incidents involving bullying are taken very seriously at WCHS. When these incidents are reported, support services can be provided to all students involved.

As stated in the WCHS Student Handbook, bullying is defined as physical or verbal conduct, by one or more students, which serves to harass, demean, humiliate, abuse, victimize, deny, or exclude one or more students from the pursuit of participation in, and/or enjoyment of any program or activity, including academic and nonacademic classes and extracurricular activities, offered or sponsored by the School District or in any facility operated by the Board of Education.

This form has been created to help provide a safe means of reporting an incident of bullying to school personnel. It is designed to remain anonymous, and it is encouraged that bystanders of bullying incidents report their observations so appropriate action can be taken. Victims of bullying and witnesses are also encouraged to use this form, as well as, reporting the incident directly to the staff at WCHS.

Thank you for taking the time to complete this form. WCHS appreciates your help in maintaining a safe environment for our students.

Your Name (Optional)

Date

YYYY

You are a: *

Student

Parent

Staff member

Other

Indicate here if you prefer to remain anonymous.

YES

Clear selection

Are you the target of the bullying or school violence that you are reporting? *

Yes

Date of Incident *

YYYY

Time of Incident

Person being bullied? *

Name of offender? *

Bullying witness *

Did you witness the bullying?

Yes

Other witnesses

How long has the bullying been going on? *

Please report whether this is the first time or if it has been going on for a longer period of time (days, weeks, etc.)

Was the incident based on any of these characteristics? (Check all that apply.) *

Race

Color

Nationality

Sex

Sexual orientation

Gender identity

Gender-related identity

Gender-related expression

Ancestry

Age

Religion

Physical disability

Mental disability

Order of protection status

Homeless status

Marital status

Parental status

Pregnancy

Associated with person/group with one or more of the above actual or perceived characteristics

I don't know

Other

Required

If you answered the previous question as "Other", please explain.

Student(s) were targeted for bullying in the following way(s): (Check all that apply): *

Electronic devices (e.g., internet, Social media platforms, text, email, cyberbullying,etc.)

Written communication (e.g., handwritten notes, other written documents, email, etc.)

Physical act or conduct (e.g., pushing, hitting, destruction of property, stalking, etc.)

Verbal act or conduct (e.g., rumors, lies, name-calling, using derogatory slurs, etc.)

Social (e.g. purposeful exclusion, causing psychological harm, etc.)

Items depicting implied hatred or prejudice were worn, possessed or displayed

Other

Required

If you answered the previous question as "Other", please explain.

Student(s) were targeted for bullying in the following place(s): (Check all that apply.) *

Classroom

Locker room

Hallway

Extracurricular activity

Cafeteria

Bus

Restroom

Bus stop

Gym

School or related activity or event

Other

Required

If you answered the previous question as "Other", please explain.

Please tell us about the incident in your own words. Use as much detail as possible - what time did the incident(s) take place, who witnessed it, what was said, what types of interactions occurred (physical, written, social, electronic, etc.) *

The above information is true and accurate to the best of my knowledge. *

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