Bullying/Harassment Anonymous Reporting
Bullying, harassment, and intimidation are serious and will not be tolerated. This is a form to report alleged
bullying, harassment, or intimidation that occurred during the current school year on school property, at a school-sponsored activity or event off school property, on a school bus, on the way to and/or from school*, or on the internet-sent
on or off school property; or that substantially disrupted the orderly operation of the school. Bullying, harassment
and intimidation includes any 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.

Definitions:
1. Bullying – A pattern or 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.
2. Cyberbullying – The use of electronic communication to harm or harass others in a deliberate, repeated, and hostile manner.
3. Harassment –Includes actual or perceived negative actions that offend, ridicule, or demean another individual with
regard to race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical
attributes, socioeconomic status, familial status, physical or mental ability, or disability.
4. Intimidation – subjecting an individual to intentional action that seriously threatens and induces a sense of fear and/or inferiority.

Where did the bullying/harassment take place?
Your answer
When did the bullying/harassment take place?
MM
/
DD
/
YYYY
Who was the victim of the bullying/harassment?
Your answer
Who was/were the offender(s) that participated in bullying or harassing?
Your answer
Describe the bullying/harassment actions that took place, including what the offenders said or did.
Your answer
Did anyone suffer physical or psychological injury due to this incident?
Please, list any witnesses to this event besides the victim and the offender(s).
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Northeast Academy. Report Abuse - Terms of Service - Additional Terms