Bullying, Harassment, Or Intimidation Reporting Form printable pdf download

, H

ULLYING

ARASSMENT OR

NTIMIDATION

EPORTING

ORM

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 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 on the internet-sent on or off school property; or that

substantially disrupted the orderly operation of the school. Bullying, harassment and intimidation mean any 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. The conduct must (1) be motivated by an actual or a perceived personal characteristic including race,

national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status,

familial status, or physical or mental ability or disability, or (2) be threatening or seriously intimidating. Electronic communication means

communication transmitted by means of electronic device, including a telephone, cellular phone, computer and pager. Conduct that is

of a sexual nature is the most commonly reported form of sexual harassment. This term is generally thought to mean actions, language

or visual materials which specifically refer to, portray or involve sexual activity or language. Conduct of a sexual nature may include

overt sexual solicitations, inappropriate touching, sexual jokes and inquiries about a person's sex life. Sexual harassment is the broader

term that encompasses conducts of a sexual nature such as unwelcomed sexual advances, requests for sexual favors, and other

verbal or physical contact of a sexual nature. Sexual harassment also includes acts that are not overtly sexual but rather are directed at

individuals based on their gender such as profanity or rude behavior that is gender-specific.

If you are a student, the parent/guardian of a student, a close adult relative of a student, or a school staff member and wish to report an

incident of alleged bullying harassment, or intimidation, complete this form and return it to the Principal at the student victim’s school.

You may contact the school for additional information or assistance at any time.

(PLEASE PRINT ALL INFORMATION)

Today’s date: _________ / _________ / ___________

School: ______________________________________________

Month

Day

Year

School System: ________________________________________

Name: ___________________________________________________

ERSON

EPORTING

NCIDENT

Telephone: ___________________________

E-mail: ___________________________________________________

Place an X in the appropriate box:  Student  Parent/guardian of a student  Close adult relative of a student  School Staff

 Bystander

1. Name of student victim: _________________________________________________ Age: _________

School _________

2. Name of alleged witness(es) (if known):

______________________________________________

Age: ________ School _____________________________

______________________________________________

Age: _________ School _____________________________

______________________________________________

Age: _________ School ____________________________

3. Name(s) of alleged offender(s) (if known):

Age

School

Is he/she a student?

___________________________________________

_______ _______________________

 Yes  No

___________________________________________

_______ _______________________

 Yes  No

___________________________________________

_______ _______________________

 Yes  No

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

_______ / ________/ _________

_______ / _______ / ________

_______ / ________/ _________

Month

Day

Year

Month

Day

Year

Month

Day

Year

Maryland State Department of Education in accordance with the Safe Schools Reporting Act of 2005

7-15

Bullying, Harassment, Or Intimidation Reporting Form

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