FormsParents & StudentsBullying → Bullying, Harassment, or Intimidation Reporting Form

Bullying, Harassment, or Intimidation Reporting Form

About this Form

Form number: 230-35

Audience:  Students

Last revised: June 2022

Related Forms

Form 230-36 - Bullying, Harassment, or Intimidation Incident School Investigation 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 personal mobile device 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 a family member 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 harmothers) and
2) Repetition (bullying behaviors happen more than once or are highly likely to be repeated based on evidence gathered).

CYBERBULLYING—is bullying transmitted by means of personal mobile devices through electronic communication that allows individuals to view or share content. Cyberbullying includes sending, posting, or sharing personal or private information about someone
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.
 

Adobe PDF Bullying, Harassment, or Intimidation Reporting Form180 KEnglish
Adobe PDF Formulario para Reportar Acoso Escolar, Hostigamiento o Intimidación59 KSpanish
Adobe PDF Formulaire pour Signaler la Brimade, le Harcèlement, ou l’Intimidation59 KFrench
Adobe PDF Đơn Báo Cáo Các Hành Động Bắt Nạt, Quấy Nhiễu hay Hăm Dọa144 KVietnamese
Adobe PDF 霸凌、騷擾或恐嚇事件報告表254 KChinese
Adobe PDF 약자 괴롭히기/왕따, 희롱 및 협박 행위 보고서240 KKorean
Adobe PDF የጉልበተኝነት፣ ትንኮሳ፣ ወይም የማስፈራራት ሁኔታ ሪፖርት ማቅረቢያ ቅጽ455 KAmharic
Adobe PDF Formulário de Denúncia de Bullying, Assédio ou Intimidação60 KPortuguese

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat