SCSD Bullying/Harassment/Intimidation/Discrimination Incident Report Form

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Directions: If you wish to report any incident(s) of bullying/harassment/intimidation/discrimination, please contact your school principal or school staff. You may also use this form to report a conflict, bullying, or other inappropriate behavior. You may fill this out for yourself or for someone else if you are being an ally for someone else.

The information that is provided will be kept confidential. The only people who have access to this report are those adults needed to assist you with a resolution.

It is important to understand that Education Code 48900 defines bullying as - Any severe or pervasive physical or verbal act or conduct, including threats made in writing or by electronic means, including one or more of the following: Sexual Harassment (48900.2), Hate Violence (48900.3) Threats, harassment, intimidation (48900.4).

Further, bullying includes one or more acts committed by a pupil or groups of pupils directed toward one or more pupils that has or can be reasonably perceived to have the effect of one or more of the following: Education Code 48900:
being dehumanizing, intimidating, hostile, humiliating, threatening, or otherwise likely to evoke fear of physical harm or emotional distress and may be motivated either by bias or prejudice based upon any actual or perceived characteristics, such as race, religion, ancestry, national origin, gender, sexual orientation, gender identity or expression, or a mental, physical or sensory disability or impairment, or by any other distinguishing characteristic.

Email *

Your First Name *

Your Last Name *

What grade are you in? Or what affiliation do you have with the school? *

Your School Name *

List the inappropriate behavior(s) you want to report. Check all that apply *

Direct physical aggression/fighting (hitting, pushing, kicking, grabbing, tripping, etc.)

Taking food or possessions

Stealing

Getting another person to hit or harm student

Teasing, name-calling, threatening language

Making rude or threatening gestures

Using racial or religious slurs

Excluding or rejecting the student

Sexual name calling

Intimidating, exploiting or extorting

Spreading harmful rumors or gossip

Other:

Required

Name of the student being targeted (Could be yourself or the person you are being an ally for) *

Grade Level of the Student Being Targeted *

What is the name(s) of the student(s) who was bullying or using inappropriate behavior? *Please use their first and last name if possible. If you don't know, you can write "I don't know" or include a description of them. *

When did the incident happen? *

YYYY

What time of day did the incident happen *

Before school

During class time

Passing period

Recess

Lunchtime

After school

Other:

Where did the incident happen? *

Classroom

Text/Computer/Social Media

Quad

Blacktop

Field

Atrium/Learning Commons

Hallway

Bathroom

PE Locker Room / Gym/ Multi Use Room

Off Campus

Other:

About how often is the behavior happening? *

Describe the incident in more detail. *

How much is the behavior affecting you? *

Is there a specific teacher, administrator or staff member whom you would feel most comfortable talking to about this? If so, write his/her/their name here.

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