Elementary Bullying Report Form
In order to promote a safe learning environment for all students, the Mid-Buchanan R-V School District prohibits all forms of bullying. The district also prohibits reprisal or retaliation against any person who reports an act of bullying among or against students.
In accordance with state law, bullying is defined as intimidation, unwanted aggressive behavior, or harassment that is repetitive or is substantially likely to be repeated and causes a reasonable student to fear for his or her physical safety or property; that substantially interferes with the educational performance, opportunities or benefits of any student without exception; or that substantially disrupts the orderly operation of the school. Bullying includes, but is not limited to: physical actions, including violence, gestures, theft, or property damage; oral, written, or electronic communication, including name-calling, put-downs, extortion, or threats; or threats of reprisal or retaliation for reporting such acts.
Cyberbullying – A form of bullying committed by transmission of a communication including, but not limited to, a message, text, sound or image by means of an electronic device including, but not limited to, a telephone, wireless telephone or other wireless communication device, computer or pager. The district has jurisdiction over cyberbullying that uses the district's technology resources or that originates on district property, at a district activity or on district transportation. Even when cyberbullying does not involve district property, activities or technology resources, the district will impose consequences and discipline for those who engage in cyberbullying if there is a sufficient nexus to the educational environment, the behavior materially and substantially disrupts the educational environment, the communication involves a threat as defined by law, or the district is otherwise allowed by law to address the behavior.
Victim/Target(s) (If you don't know their name, please do your best to describe them.):
Name of person making the report (Optional)
Role of person making the report:
Member of the Community
Best way to contact you for follow-up questions (Please include a phone number or email address)
Name of aggressor/bully (Person who engaged in the behavior. If you don't know their name, please do your best to describe them.):
Select the bullying behavior (select all that apply):
Cyber-bullying (text, website, email, other)
Racial, Sexual, Religious, or Disability
Hit, Kicked, Punched
Told Lies or False Rumors
What happened? Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).
Did anyone else see the incident happen? (List people who saw the incident or have information about it)
What day did this happen?
Where did this happen?
On school property
At a school-sponsored activity or event off school property
On a school bus
On the way to/from school
Outside of school
Electronically (text, social media, e.g.)
Has this behavior happened before?
If yes, please describe the event in detail.
Have you reported this event to anyone?
If yes, who did you report to about the problem?
Other family member
Other staff member
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)?
Is there any other information you would like to provide?
Never submit passwords through Google Forms.
This form was created inside of Midbuchanan.k12.mo.us.