BULLYING, HARASSMENT, OR INTIMIDATION REPORTING FORM

Directions:
The Bullying, Harassment or Intimidation Reporting Form should be used to report alleged incidents of
bullying, harassment, or intimidation that occurred during the current school year on school property, at a
school-sponsored activity or event off school property, on a school bus, on the way to and/or from school,
or through electronic communication on or off school property. School staff will address incidents that occur
at school or have a connection or nexus back to the school setting that create a risk of harm to other
students while they are at school or interfere with the educational environment.
If you are a student, the parent/guardian or caregiver of a student, a close adult relative of a student, a
school staff member, or a bystander and wish to report an incident of alleged bullying, cyberbullying,
harassment, or intimidation, please complete this form, and return it to the school principal.
You may contact the school for additional information or assistance at any time. (Bullying, cyberbullying,
harassment, and intimidation definitions are provided below.)

Definitions:
Bullying– is unwanted, demeaning behavior among students that involves a real or perceived power
imbalance. The behavior is repeated, or is highly likely to be repeated, over time. In order to be considered
bullying, the behavior must be intentional and include: 1) An imbalance of power (students who bully use
their physical, emotional, social, or academic power to control, exclude, or harm others), and 2) Repetition
(bullying behaviors happen more than once or are highly likely to be repeated based on evidence
gathered).

Cyberbullying– is bullying that takes place over digital devices like cell phones, computers, and tablets.
Cyberbullying can occur through texting, apps, or online via social media, forums, or gaming where people
can view, participate in, or share content. Cyberbullying includes sending, posting, or sharing negative,
harmful, false, or hurtful content about another student. It can include sharing personal or private
information about someone else causing embarrassment or humiliation.

Harassment – includes actual or perceived negative actions that offend, ridicule, or demean another
student with regard to race, ethnicity, national origin, immigration status, family/parental or marital status,
sex, sexual orientation, gender identity, gender expression, religion, ancestry, physical attributes,
socioeconomic status, physical or mental ability, or disability.

Intimidation – is any communication or action directed against another student that threatens or induces a
sense of fear and/or inferiority. Retaliation may be considered a form of intimidation.

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 BULLYING, HARASSMENT, OR INTIMIDATION REPORTING FORM
(PLEASE PRINT ALL INFORMATION)
Today’s date: _________ / _________ / ___________ School: ______________________________________________
Month Day Year

PERSON REPORTING INCIDENT Name: ______________________________________________

Telephone: ___________________________ E-mail: _________________________________________________

Place an X in the appropriate box: Student Parent/guardian/caregiver of a student Close adult relative of a student
School staff Bystander

1. Alleged Targeted Student(s)

Name: Age: Days absent as a result
of the incident: (if known)

2. Alleged Offender(s) (if known)

Name School: (if known) Age: (if Student: Days absent as a result
known) (Y/N) of the incident: (if known)

3. Alleged Witness(es) (if known)

Name School: (if known) Age: (if Student:
known) (Y/N)

4. On what date(s) did the incident(s) happen?

_______ / ________/ _________ _______ / _______ / ________ _______ / ________/ _________

Month Day Year Month Day Year Month Day Year

5. Place an X next to the statement(s) that best describes what happened (choose all that apply):
❑Actions/comments related to the student’s race/ethnicity Demeaning behavior just to be mean
❑Actions/comments related to the student’s national origin. An act or threat of retaliation

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❑Actions/comments related to the student’s religion Gang related/gang recruitment
❑Actions/comments related to the student’s sex Human trafficking/prostitution recruitment
❑Actions/comments related to the student’s Immigration status Any bullying, harassment, or intimidation that involves physical aggression
❑Actions/comments related to the student’s Cyberbullying (social media, text messages, etc.)
family/parental or marital status Teasing, name-calling, making critical remarks
❑Actions/comments related to the student’s socio-economic status Demeaning or making the student the target of jokes
Actions/comments related to the student’s academic performance Making rude and/or threatening gestures
❑Actions/comments related to the student’s Excluding or rejecting the student
perceived sexual orientation Intimidating, extorting, exploiting the student
❑Actions/comments related to the student’s gender expression Getting another person to target or demean the student
❑Actions/comments related to the student’s gender identity Spreading hurtful rumors or gossip
❑Actions/comments related to the student’s disability Racial/ethnic harassment
❑Actions/comments related to the student’s physical appearance Sexual harassment
Demeaning behavior to impress others Other: (Please Specify) __________________________
6. Where did the incident happen? (Place an X next to the statement(s); choose all that apply)
On school property (please specify location) ________________________
On the way to/from school*
On a school bus
Off school property or at a school-sponsored activity or event
Digital device on school property Digital device off school property During virtual learning
Other (please specify): ________________________________________________________
*Will be collected unless specifically excluded by local board policy
7. Describe the incident(s), including what the alleged offender(s) said or did.

8. Why do you think the bullying, cyberbullying, harassment, and/or intimidation occurred?

9. Did a physical injury result from this incident? Place an X next to one of the following:
No Yes, but it did not require medical attentionYes, and it required medical attention
10. If there was a physical injury, do you think there will be permanent effects? Yes No
11. Was the student victim absent from school as a result of the incident? Yes No
If yes, how many days was the student victim absent from school as a result of the incident? _________
12. Did a psychological injury result from this incident? Place an X next to one of the following:
No Yes, but psychological services have not been sought Yes, and psychological services have been sought
13. Is there any additional information you would like to provide?

Signature: _________________________________________________________________ Date: ___________

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