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 on school property; at a school-sponsored activity or event off school property; on a school bus; or on the way to and/or from school*, in the current school year. If you are a student victim, the parent/guardian of a student victim, or a close adult relative of a student victim, or a school staff member and wish to report an incident of alleged bullying harassment, or intimidation, complete this form and return it to the Principal at the student victim’s school. Contact the school for additional information or assistance at any time.

Bullying, harassment, or intimidation means intentional conduct, including verbal, physical, or written conduct, or an intentional electronic communication, that: (I) 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 (II) 1. occurs on school property, at a school activity or event, or on a school bus; or 2. substantially disrupts the orderly operation of a school. Electronic communication means a communication transmitted by means of an electronic device, including a telephone, cellular phone, computer, or pager.

Person Reporting Incident

Incident

Information of Alleged Offender(s)

On what date(s) did the incident happen?

Select the statement(s) that best describes what happened (choose all that apply)

Where did the incident happen (choose all that apply)

Did a physical injury result from this incident

If there was a physical injury, do you think there will be permanent effects

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

Did a psychological injury result from this incident

By signing this report form, I attest that all information on this form is accurate to the best of my knowledge and I understand the serious nature of this report. By signing this report form, I understand and agree to be contacted by school, local, state or federal authorities to assist in the matters of this report.