Bullying Report Form

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Williams Unified School District #2 is committed to providing a safe learning environment for all students. This form may be used by students to report being bullied or by someone witnessing a student being bullied.

School where incident occurred *

Williams Elementary-Middle School

Williams High School

Select which apply to you *

Student

Parent/Guardian

School Staff

Community Member

Location where incident occurred *

Bus

Cafeteria

Classroom

Locker Room

Playground

Restroom

Off Campus

Other:

Bullying Incident

Name (s) of alleged offenders--if name(s) are known, include to help investigation. *

Please describe the bullying incident. Try to include as many details as possible. *

Check all that apply *

Cyberbullying Definition: the use of electronic communication to bully a person, typically by sending messages of an intimidating or threatening nature.

Hazing Definition: the imposition of strenuous, often humiliating, tasks as part of a program of rigorous physical training and initiation.

Intimidation Definition: the action of intimidating someone, or the state of being intimidated.

Name-calling Definition: a form of verbal abuse in which insulting or demeaning labels are directed at an individual or group.

Physical Violence Definition: Any act where an individual attempts to harm another through physical means

Public Humiliation Definition: a form of punishment whose main feature is dishonoring or disgracing a person, usually an offender or a prisoner, especially in a public place

Social Exclusion Definition: a form of discrimination. It occurs when people are wholly or partially excluded from participating in the economic, social and political life of their community, based on their belonging to a certain social class, category or group

Threat Definition: a statement of an intention to inflict pain, injury, damage, or other hostile action on someone in retribution for something done or not done.

Unwanted Touching Definition: any form of touch that makes a person feel uncomfortable

Other:

Required

Person Reporting Incident

Name (optional. please provide contact information if you would like a follow up)

Phone (optional)

E-Mail (optional)

By completing this form, you are verifying that your statements are true and accurate to the best of your knowledge.

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This form was created inside of WILLIAMS UNIFIED SCHOOL DISTRICT. Report Abuse

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