SUESD Bullying Incident Reporting Form
SUESD defines bullying as a pattern of behavior when a person repeatedly uses power in an intentional manner, including verbal, physical, or written conduct or intentional electronic communication against one or more students. Harassment includes actual or perceived negative actions that offend, ridicule, or demean another individual with regard to race, national origin, marital status, gender, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, physical or mental ability, or disability. Intimidation is subjecting an individual to intentional action that seriously threatens and induces a sense of fear and/or inferiority. Bullying, cyberbullying, harassment, and intimidation are strictly prohibited by federal law and will not be tolerated in Soquel Union Elementary Schools (Board of Education Policy 5131.2). Students who engage in behaviors that constitute bullying, cyberbullying, harassment, or intimidation will be disciplined according to the procedures set forth in this Student Handbook and Soquel Union Elementary School Districts regulations. Students, parents and close relatives, and/ or staff are encouraged to report any acts of the above to the school administration or designee.
1. I am a: *
2. Person/People bullying: If you do not know the name of the person/people bullying, simply do your best to describe the individual(s). *
Your answer
3. Person/people being bullied: If you do not know the name of the person/people being bullied, simply do your best to describe the individual(s). *
Your answer
4. Date of Incident *
MM
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DD
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YYYY
5. Approximate Time of Incident *
Time
:
6. Which School is this report regarding? *
7. Specific Location of Incident *
Your answer
8. Type of Bullying *
9. Description of Incident *
Your answer
10. Witnesses / Bystanders: Please list anyone who was present during the incident, as well as anyone you have told about the incident. Write "none" if there were not witnesses or bystanders. *
Your answer
11. Optional Question: Are you aware of any previous incidents of bullying involving these same students?
Your answer
12. Optional Contact Information: If you wish to remain anonymous, simply leave this field blank. If you do not wish to remain anonymous, please leave your name and e-mail address here. You may also leave a phone number if you wish.
Your answer
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