Report Bullying

Directions

The Bullying, Harassment, or Intimidation Reporting form should be used to report alleged incidents of 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 through electronic communication on or off school property. School staff will address incidents that occur at school or have a connection or nexus back to the school setting that create a risk of harm to other students while they are at school or interfere with the educational environment. 

If you are a student, the parent/guardian or caregiver of a student, a close adult relative of a student, a school staff member, or a bystander, and wish to report an incident of alleged bullying, cyberbullying, harassment, or intimidation, please complete this online form. If you need to complete the form in a different manner, please contact the school.

You may contact the school for additional information or assistance at any time.

(Bullying, cyberbullying, harassment, and intimidation definitions are provided below.)

Bullying is unwanted, demeaning behavior among students that involves a real or perceived power imbalance. The behavior is repeated, or is highly likely to be repeated, over time. In order to be considered bullying, the behavior must be intentional and include: 1) An imbalance of power (students who bully use their physical, emotional, social, or academic power to control, exclude, or harm others), and 2) Repetition (bullying behaviors happen more than once or are highly likely to be repeated based on evidence gathered).

Cyberbullying is bullying that takes place on digital devices like cell phones, computers, and tablets. Cyberbullying can occur through texting, apps, or online via social media, forums, or gaming, where people can view, participate in, or share content. Cyberbullying includes sending, posting, or sharing negative, harmful, false, or hurtful content about another student. It can include sharing personal or private information about someone else, causing embarrassment or humiliation. 

Harassment includes actual or perceived negative actions that offend, ridicule, or demean another student with regard to race, ethnicity, national origin, immigration status, family/parental or marital status, sex, sexual orientation, gender identity, gender expression, religion, ancestry, physical attributes, socioeconomic status, physical or mental ability, or disability.

Intimidation is any communication or action directed against another student that threatens or induces a sense of fear and/or inferiority. Retaliation may be considered a form of intimidation.

Bullying, Harrassment, and Intimidation Form

1. Today's Date: 

2. School:

3. Name: 

4. Phone Number: 

5. Email Address: 

6. I am a: (check the appropriate answer)

7. Alleged Targeted Student(s): 

Student Name: 

Student Age: 

Days Absent: 

8. Alleged Offender(s) (if known):

Offender Name: 

School Name: 

Age: 

Student (Y/N): 

Offender Days Absent: 

9. Alleged Witness(es) (if known):

Witness Name: 

Witness School: 

Witness Age: 

Witness Student (Y/N): 

10. On what date(s) did the incident(s) happen? 

11. Select which statement(s) best describes what happened (choose all that apply):

12. Where did the incident happen? (choose all that apply)

13. Describe the incident(s), including what the alleged offender(s) said or did: 

14. Why do you think the bullying, cyberbullying, harassment, and/or intimidation occurred? 

15. Did a physical injury result from this incident? (choose one of the following):

16. If there was a physical injury, do you think there will be permanent effects? (choose one of the following):

17. Was the student victim absent from school as a result of the incident? 

18. If yes, how many days was the student victim absent from school as a result of the incident? 

19. Did a psychological injury result from this incident? (choose one of the following)

20. Is there any additional information you would like to provide? 

21. Electronic Signature: 

22. Date: 



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