Report a Bullying Incident

Bullying, harassment, or intimidation means 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 and is: 1. motivated by an actual or a perceived personal characteristic including race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attribute, socioeconomic status, familial status, or physical or mental ability or disability; or 2. threatening or seriously intimidating; and substantially disrupts the orderly operation of a school.

Harassment and bullying are serious and will not be tolerated. This form is used to report this behavior if it occurs on school property or at a school sponsored event during the current school year. If you feel you are being bullied or harassed you need to speak with an adult. There are people in the building to assist you. Please notify your Anti-Bullying Coordinator.

Today's Date	MM / DD / YYYY
Person Reporting Incident	First Last
You are a	Student   Parent/Guardian   Staff   Friend/Relative
Phone Number	### - ### - ####
Email
Name and grade/age of targeted student(s)
Name and grade/age of alleged offender(s)
On what date did the incident occur?	MM / DD / YYYY
Additional dates
Where did the incident occur?
Place a check next to the statement(s) that best describe what happened:	Hitting, kicking, shoving, or throwing something   Getting another person to hit or harm the student   Teasing, name-calling, making critical remarks or making threats   Making rude and/or threatening gestures   Excluding or rejecting the student   Intimidating (bullying) extorting or exploiting   Spreading harmful rumors or gossip   Cyberbullying   Other
What happened?
Why did the harassment or bullying occur?
Was there an injury?	Yes   No
If so, what kind of injury?
Is there any additional information that you would like to provide?