Bullying Incident Report-Student Form

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Bullying/Harassment Policy:

Bullying is a distinctive pattern of repeatedly and deliberately harming and humiliating others and is characterized by a power imbalance between the two parties. Bullying includes, but is not limited to physical or verbal aggression, relational aggression, or emotional aggression (teasing, threatening, and intimidating others). Relational aggression (RA), is a form of indirect bullying that uses social relationships to manipulate or harm others, such as isolating a student from her group of friends (social exclusion), threatening to stop talking to a friend (the ''silent treatment''), or spreading gossip and rumors. Harassment includes, but is not limited to, slurs, jokes, comments, or other offensive conduct relating to race, religion, color, sex, sexual orientation, national origin, citizenship, disability, or any other legally protected characteristic. Bullying, relational aggression (including cyber-bullying), and harassment will not be tolerated.

Please use this form to report bullying.

Please note: False reports of or retaliation for bullying also constitutes violations of this policy.

Name of individual completing report

Date *

YYYY

Name of student being bullied. *

Grade of student being bullied *

8th

9th

10th

11th

12th

Unknown

Name of student accused of bullying *

Grade of student accused of bullying *

8th

9th

10th

11th

12th

Unknown

Date of incident

YYYY

Time of incident

Time

Nature of bullying being reported:

(Check all that apply)

Physical: hitting, spitting, kicking, or damaging your or another student's possessions

Verbal: saying mean or hurtful things or threatening you or another student

Social: excluding you or a student from a group, telling peers not to talk to you or another student

Emotional: spreading rumors or lies about someone, mocking or teasing

Cyber/Online: verbal/social/emotional bullying that occurs on a website, social media or via cell phone, emails, or text message

Other:

Required

In as much detail as possible, please explain the incident.

Did you witness the event?

Yes

Were there any other witnesses?

Yes

Unknown

If there were other witnesses, please list their names and grade below:

(If there were no witnesses, enter "none".)

I am submitting this form based on my belief that bullying has occurred and I am reporting this because I am concerned and want to the situation to be better in the future.
*

Yes

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