River Bend Middle School Student Safety Concerns

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BULLYING, INTIMIDATION, AND HARASSMENT
Bullying, intimidation, and harassment diminish a student’s ability to learn and a school’s ability to educate. Preventing students from engaging in these disruptive behaviors is important .

Bullying and/or Intimidation is defined as: Repeated intentional behavior by an individual with power over the victim or victims. Such behavior may include, physical, verbal, written or electronic communication or conduct of a belittling or browbeating nature.

Please use this form carefully, think about what has happened and express yourself to the best of your ability.

Your Name (*This is required and will be kept confidential) *

Date *

Contact Info ( home/cell/email) *

Name of adults you have contacted.

Name of Accused *(This will be kept confidential) *

Please check the box or boxes that best describe what the accused did. *

Physical: Hitting, kicking, shoving, spitting, etc.

Teasing, name calling, put downs, criticizing

Threatening in person, by phone, by e-mail, etc.

Demanding money/homework, etc.

Getting another person to hit or harm a student

Property issues ( hiding of property, damaging, taking)

Making rude and /or threatening gestures

Spreading harmful rumors, gossip or photos

Bullying

Other:

Required

Description of current incident. Include date and time *

Where did the incident happen? *

If you marked "other" on the previous question, please explain.

Please list any witness.

Any previous incidents, please explain

How did you respond to the incident?

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