NYCS Bullying Incident Report Form

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This form is intended for reporting bullying incidences that occur in the Nelsonville-York City School District.

Statement of Understanding: I acknowledge that by submitting this report I understand that harassment, bullying, and intimidation is defined by the Ohio Revised Code as “intentional written, verbal, graphic, physical or electronic act that a student or group of students exhibited toward the alleged victim more than once; and the behavior both causes mental or physical harm to the other student, and is sufficiently severe, persistent or pervasive that it creates an intimidating, threatening or abusive educational environment for the other student (ORC3313.666) and that false reports will result in disciplinary action pursuant to the Student Code of Conduct that may include, but not limited to: detention, suspension, and/or expulsion depending on the circumstances *

Checking this box indicates acknowledgement of the statement above

Required

School where incident occurred *

Location of Incident (check all that apply)

Hallway

Restroom

Classroom

Lunch Room

Locker Room

Bus Stop

On Bus

Parking Lot

Gym

After School Program

School Sponsored Event

Text/Phone/Internet/Social Media

Other:

Person Reporting Incident

Name

Phone

Select which apply to you

Student

Parent/Guardian

School Staff

Community Member

Have you reported to an adult *

Yes

Bullying Incident

Name(s) of alleged offenders *

Name(s) of alleged victims *

Please describe the bullying incident *

Bullying Behaviors (check all that apply) *

Shoved/Pushed

Excluded

Staring/Leering

Hit, Kicked, Punched

Taunting/ridiculing

Intimidation/Extortion

Threatened

Writing/Graffiti

Demeaning Comments

Stole/Damaged Possessions

Told Lies or False Rumors

Inappropriate Touching

Cyberbullying

Required

If cyberbullying occurred was it through text, website, email or other.

Indicate if you think the incident was motivated by racism, homophobia, transphobia, disability or a form of sexual harassment.

I acknowledge this report is accurate and contains factual information only and that I will be subject to discipline for false reporting in compliance with the policy of the Board of Education and the Student Handbook.I acknowledge that the administration will complete their investigation in compliance with policy and that any potential intervention and action will also be in compliance with policy and the individual rights of all of the involved students.I acknowledge that the Nelsonville Police Department and other law enforcement entities may be involved in matters pertaining to electronic, and other harassment occurrences, that take place outside of school or that involve the illegal distribution of images or in any other way are unlawful.I acknowledge that the district interventions may include, and are not limited to, the involvement of district employed Case Worker, Guidance Counselors, School Resource Officers, School Nurses, and other personnel where necessary. By entering my name below I acknowledge my full understanding and agreement of all of the statements listed above. *

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