Montgomery County Public Schools

Bullying, Harassment, or Intimidation Reporting Form

DIRECTIONS: Complete this form 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. Return the completed form to the Principal at the alleged student victim’s school. Contact the school for additional information or assistance at any time. Bullying, harassment, or intimidation are serious and will not be tolerated.

In accordance with Maryland law, bullying, harassment, or intimidation means intentional conduct, including verbal, physical, or written conduct or an intentional electronic communication that creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities, or performance, or with a student’s physical or psychological well-being, and is:

(1) Either (a) motivated by an actual or perceived personal characteristic including race, ethnicity, color, ancestry, national origin, religion, immigration status, sex, gender, gender identity, gender expression, sexual orientation, family/parental status, marital status, age, physical or mental disability, poverty and socioeconomic status, or language, or other legally or constitutionally protected attributes or affiliations; (b) sexual in nature; or (c) threatening or seriously intimidating; and

(2) Either (a) occurs on school property, at a school-sponsored activity or event, or on a school bus; or (b) substantially disrupts the orderly operation of a school.

Cyberbullying is a form of bullying, harassment, and intimidation. “Cyberbullying” means a communication transmitted by means of an electronic device and includes the use of social media sites. Cyberbullying shall include any future applications that fall under “electronic communication.” “Electronic communication” means a communication transmitted by means of an electronic device, including a telephone, cellular phone, computer, or tablet.

Bullying, Harassment, or Intimidation Reporting Form	182 K	English
Formulario para Reportar Acoso Escolar, Hostigamiento o Intimidación	59 K	Spanish
Formulaire pour Signaler la Brimade, le Harcèlement, ou l’Intimidation	59 K	French
Đơn Báo Cáo Các Hành Động Bắt Nạt, Quấy Nhiễu hay Hăm Dọa	144 K	Vietnamese
霸凌、騷擾或恐嚇事件報告表	254 K	Chinese
약자 괴롭히기/왕따, 희롱 및 협박 행위 보고서	240 K	Korean
የጉልበተኝነት፣ ትንኮሳ፣ ወይም የማስፈራራት ሁኔታ ሪፖርት ማቅረቢያ ቅጽ	455 K	Amharic
Formulário de Denúncia de Bullying, Assédio ou Intimidação	60 K	Portuguese

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