Bullying, Harassment or Intimidation Reporting Form

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DIRECTIONS: Bullying, harassment and 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 in the current school year.

If you are a student victim, the parent/guardian of a student victim, 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.

Contact the school for additional information or assistance at any time. If a threat of suicide is reported, the principle/designee will inform the parent or guardian.

Today's Date

YYYY

Student attends which school?

Radney Elementary School

Clear selection

Name of Student Victim

Grade of Victim

Name(s) of alleged offender(s) (If Known)

Age(s) of alleged offender(s) (If Known)

Is he/she a student?

Yes

Maybe

Clear selection

School alleged offender(s) attends: (If Known)

Jim Pearson Elementary

Stephens Elementary

Radney Elementary

Alexander City Middle School

Benjamin Russell High School

Unknown

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On what date did the initial incident happen:

YYYY

If applicable, on what date did an additional incident happen?

YYYY

If applicable, on what date did an additional incident happen?

YYYY

Where did the incident(s) happen?

On school property

Off school property

On a school bus

At a school-sponsored activity or event off school property

Clear selection

Choose the best statement that describes what happened

Hitting

Kicking

Shoving

Spitting

Hair Pulling

Throwing something

Coercing another person to hit or harm the student

Repeated teasing

Name calling

Making critical remarks

Threatening gestures

Rude gestures

Intimidating

Bullying

Extorting

Exploiting

Spreading harmful rumors

Spreading gossip

Cyberbullying

Did a physical or psychological injury result from this incident?

Yes

Maybe

Clear selection

If yes, explain

Was the victim absent from school as a result of this incident?

Yes

Clear selection

If yes, how many days?

Option 6

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What did the alleged offender(s) say or do?

Why did the bullying, harassment or intimidation occur?

Is there any additional information that you would like to provide?

Name of person reporting incident

Telephone Number

E-mail (if available)

What relation are you to victim?

Student (victim)

Student (witness/bystander)

Parent/Guardian

School Staff

Other

Clear selection

I certify that there is no falsification of the above information and events are accurately depicted to the best of my knowledge.

Check if above is true

Check box below to signify you are signing this report

Electronic Signature verification box

Date

YYYY

Submit

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This form was created inside of Alexander City Schools. Report Abuse

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