Fulton Elementary School Student Safety Concerns
BULLYING, INTIMIDATION, AND HARASSMENT
Bullying, intimidation, and harassment diminish a student’s ability to learn and a school’s ability to educate. Preventing students from engaging in these disruptive behaviors is important .
Bullying and/or Intimidation is defined as: Repeated intentional behavior by an individual with power over the victim or victims. Such behavior may include, physical, verbal, written or electronic communication or conduct of a belittling or browbeating nature.
Please use this form carefully, think about what has happened and express yourself to the best of your ability.
* Required
Your Name (*This is required and will be kept confidential)
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Your answer
Date
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Your answer
Contact Info ( home/cell/email)
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Your answer
Name of adults you have contacted.
Your answer
Name of Accused *(This will be kept confidential)
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Your answer
Please check the box or boxes that best describe what the accused did.
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Physical: Hitting, kicking, shoving, spitting, etc.
Teasing, name calling, put downs, criticizing
Threatening in person, by phone, by e-mail, etc.
Demanding money/homework, etc.
Getting another person to hit or harm a student
Property issues ( hiding of property, damaging, taking)
Making rude and /or threatening gestures
Spreading harmful rumors, gossip or photos
Bullying
Other:
Required
Description of current incident. Include date and time
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Your answer
Where did the incident happen?
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Choose
Classroom
Hallway
Parking lot
Restroom
Gym/Locker Room
Lunch room
School Bus
To and from school
Playground
Internet/Cell Phone
Other
If you marked "other" on the previous question, please explain.
Your answer
Please list any witness.
Your answer
Any previous incidents, please explain
Your answer
How did you respond to the incident?
Your answer
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