MEPS HIB Anonymous Reporting Form
“Harassment, Intimidation, or Bullying” is defined as a single (or series of) action or gesture which:
Is reasonably perceived as being motivated either by an actual or perceived characteristic, such as: race, color, religion, ancestry, national origin, gender, sexual orientation, gender identity and expression, or a mental, physical or sensory disability, or by any other distinguishing characteristic…
AND
Is communicated to another (or others) in written, verbal, physical, or electronic form
AND
Takes place on school grounds, at any school-sponsored function, on a school bus, or off school grounds substantially disrupts or interferes with the orderly operation of the school or the rights of other students, and that:
AND
A reasonable person should know, under the circumstances, will have the effect of physically or emotionally harming a student or damaging the student’s property, or placing a student in reasonable fear of physical or emotional harm to his/her person or damage to his/her property
AND
Has the effect of insulting or demeaning any student or group of students
AND
Creates a hostile educational environment for the student by interfering with the student’s education or by severely or pervasively causing physical or emotional harm to the student.


If you have information regarding bullying and would like to report this information anonymously, please fill out the blues lines in this form to the best of your knowledge. Please note that this form is completely anonymous. (For the purpose of this form, bullying encompasses bullying, harassment, and discrimination as described directly above).

Today's Date *
MM
/
DD
/
YYYY
Alleged Target Name (last, first, middle) *
Your answer
Gender *
Age *
Your answer
Grade *
Your answer
Alleged Offender Name (last, first, middle) *
Your answer
Gender *
Age *
Your answer
Grade
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of Mt. Ephraim Public Schools. Report Abuse - Terms of Service - Additional Terms