Bullying, Harassment, or Intimidation Incident School Investigation Form

 
Page 1 of 1
 
 Bullying, Harassment or Intimidation Reporting 
Directions: Bullying, harassment, or 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.

 
  Custom Image
   
  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 for Bullying, Cyberbullying, Harassment, and Intimidation are provided below.)

1. Bullying - 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.
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 identify, 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.

Conduct that is of a sexual nature is generally thought to mean actions, language, or visual materials which specifically refer to, portray, or involve sexual activity or language. Conduct of a sexual nature may include overt sexual solicitations, inappropriate touching, sexual jokes, and inquiries about a person's sex life. Sexual harassment is the broader term that encompasses conduct of a sexual nature such as unwelcomed sexual advances, requests for sexual favors, and other verbal or physical contact of a sexual nature. Sexual harassment also includes acts that are not overtly sexual but rather are directed at individuals based on their gender such as profanity or rude behavior that is gender-specific.

If you are a student, the parent/guardian of a student, a close adult relative of a student, or a school staff member and wish to report an incident of alleged bullying harassment, or intimidation, complete this form. You may contact the school for additional information or assistance at any time.
   

 
1.
  Select Date
mm/dd/yyyy
   
2.
*
 
   

 
  PERSON REPORTING INCIDENT - School administration may need to contact you for further information.
   
3.
*
 
   
4.
*
 
   
5.
 
   
6.
 
   
7.
*
(Person completing this form)
 
*
(Person completing this form)
          

   

 
8.
*
 

 

 

 
   
9.
 

 

 

 
   
10.
 

 

 

 
   
11.
 

 

 

 
   
12.
 

 

 

 
   
13.
 

 

 

 
   
14.
*
 

 

 

 

 
   
15.
 

 

 

 

 
   
16.
 

 

 

 

 
   
17.
*
  Select Date
mm/dd/yyyy
   
18.
  Select Date
mm/dd/yyyy
   
19.
  Select Date
mm/dd/yyyy
   
20.
*
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

    
   
21.
*
* Will be collected unless specifically excluded by local board policy.
 
  
  
  
  
  
  
   
22.
*
(Enter as much detail as possible)
 
   
23.
*
(Enter as much detail as possible)
 
   
24.
*
 
*



   
25.
 
   
26.
*
 
*



    
   
27.
*
 
*



   
28.
 
   
29.
 
  
   
 
 
 
 Done  Cancel