Harassment/Bullying Incident Form
Submission Instructions
Please complete all sections of this form, and visit the main office of your (the student’s) building with any evidence that supports this report.
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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.
Electronic Signature of Reporting Party *
Date *
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