Directions: Bullying, harassment, or intimidation are serious and will not be tolerated. This is a form to report alleged bullying, harassment, or intimidation that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; or on the way to and/or from school*, in the current school year. If you are a student victim, the parent/guardian of a student victim, a close adult relative of a student victim, or a school staff member and wish to report an incident of alleged bullying, harassment or intimidation, complete this form and return it to the Principal at the student victim’s school. Contact the school for additional information or assistance at any time.
Bullying, harassment, or intimidation means intentional conduct, including verbal, physical, or written conduct or an intentional electronic communication* that creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities, or performance, or with a student’s physical or psychological well-being and is:
• motivated by an actual or a perceived personal characteristic including race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, or physical or mental ability or disability; or,
• threatening or seriously intimidating; and,
• occurs on school property, at a school activity or event, or on a school bus; or,
• substantially disrupts the orderly operation of a school.
*“Electronic communication” means a communication transmitted by means of an electronic device, including a telephone, cellular phone, computer, or pager.
Upon submission the following personnel will be immediately notified via email:
The Principal (District HIB coordinator or supervisor );
the social worker (district HIB coordinator or supervisor );
the student facilitator, and any other staff member selected at the end of this form.