SAFE SCHOOL REPORT / BULLYING

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Bullying among children is commonly defined as intentional, repeated hurtful acts, words or others behaviors committed by one or more children against another. Bullying may be physical, verbal, social/emotional or sexual in nature. There are three aspects of this hurtful behavior that almost all experts agree on; in bullying there is a difference in power between those being hurt and those doing the hurting, bullying involves hurtful behaviors that are repeated and intentional.

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.

Name of Victim: *

Name of Student(s) bullying:

Name of Witnesses / bystanders:

Your Name (optional)

Person Reporting Incident

Location of Incident

Hallway

Restroom

Classroom

Gym

Locker Room

Playground

To / From School

After School Program

Text / Phone / Internet / Social Media

Other:

Clear selection

Date of Incident *

YYYY

Time of Incident *

Time

Repeat infraction?

Yes

Clear selection

Type of Bullying:

Physical

Verbal

Relational

Other:

Clear selection

Bullying Behaviors

Any bullying, harassment, or intimidation that involves physical aggression (specify)

Getting another person to hit or harm the student

Teasing, name-calling, making critical remarks, or threatening, in person or by other means

Demeaning and making the victim of joke

Making rude and/or threatening gestures

Excluding or rejecting the student

Intimidating, extorting, or exploiting

Spreading harmful rumors or gossip

Related to the student’s disability

Related to the student’s perceived sexual orientation

Cyber bullying (e.g. social media including Facebook, Twitter, Vine, Snapchat, Periscope, kik, Instagram, etc.)

Electronic communication (e.g. email, text, sexting, etc.)

Gang related

Racial Harassment

Sexual Harassment

Sexual in nature

Other:

Describe the incident:

Why did the bullying, harassment or intimidation occur?

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