Sebeka School - Bullying Report Form
The person REPORTING the bullying incident has the option of including his or her name on this form OR submitting the form anonymously. Anonymous reports are more difficult to investigate.

According to our School Board policy as found in our school's handbook, “Bullying” means intimidating, threatening, abusive, or harming conduct that is objectively offensive and:

1. an actual or perceived imbalance of power exists between the student engaging in the prohibited conduct and the target of the prohibited conduct, and the conduct is repeated or forms a pattern; or

2. materially and substantially interferes with a student’s educational opportunities or performance or ability to participate in school functions or activities or receive school benefits, services, or privileges.

Please answer all sections that apply and submit this form. It will, according to MN state law, be investigated within three school days.

Thank you for helping to keep our school safe!

Are you a:
Required
Your Name (optional)
Your answer
Date & time of the incident
Your answer
Location of the incident (hallway, playground, etc.)
Your answer
Person or persons doing the bullying
Your answer
Name/grade of the person who was the victim, if not you:
Your answer
If you were not the victim, how did you learn about the alleged bullying incident?
Your answer
Describe what took place, such as the type of bullying (verbal, written, or online), and any other important information.
Your answer
Name/names of anyone else who witnessed the incident:
Your answer
This report is filed based on my honest belief that ____________________ has bullied or was violent to another person or me. I certify this information is true and complete to the best of my knowledge
Clicking submit at the end of this report confirms this statement.
Your answer
Submit
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