Bullying Incident Reporting Form printable pdf download

Greenfield-Central Community School Corporation

Bullying Incident Reporting Form

Name of Person Completing Form (may remain anonymous): _____________________________________ Date of Form Submission: __________

Definition of Bullying: "Bullying" means overt, unwanted, repeated acts or gestures, including verbal or written communications or images transmitted in any

manner (including digitally or electronically), physical acts committed, aggression, or any other behaviors, that are committed by a student or group of students

against another student with the intent to harass, ridicule, humiliate, intimidate, or harm the targeted student and create for the targeted student an objectively

hostile school environment that:

(1) places the targeted student in reasonable fear of harm to the targeted student's person or property;

(2) has a substantially detrimental effect on the targeted student's physical or mental health;

(3) has the effect of substantially interfering with the targeted student's academic performance; or

(4) has the effect of substantially interfering with the targeted student's ability to participate in or benefit from the services, activities, and privileges

provided by the school.

Date and Time of Incident(s): ___________________________ Location of Incident(s): _______________________

Student(s) Initiating Alleged Bullying: _____________________________

____________________________ ______________________________

Student(s) Affected: ________________________________

______________________________

____________________________

Student Witness(es): ________________________________ ______________________________

____________________________

Check all spaces below that apply to the alleged incidents:

______ Name calling

______ Writing / graffiti

______ Damaging property

______ Spitting

______ Shoving / pushing

______ Inappropriate touching

______ Stalking

______ Threatening

______ Intimidation / extortion

______ Demeaning comments

______ Hitting / kicking

______ Intentional exclusion

______ Inappropriate gesturing

______ Taunting / ridiculing

______ Cyberbullying / text message

______ Stealing

______ Showing a weapon

______ Other ___________________

______ Staring / leering

Background:

______ Has there been a history between the individuals?

______ Were the actions unwanted?

______ Is there an imbalance of power?

______ Were the actions deliberate and meant to harm the other student?

______ Has this or a similar incident happened before?

Describe the incident:

_______________________________________________________________________________________________________________________________

Physical evidence:

______ Graffiti

_____ Websites/Social Media

_____ Text Message

______ Notes

_____ Voice Message

_____ Other: _____________________

______ Email

_____ Video Recording

Steps the student has taken to deal with the issue (choose all that apply):

___ Avoided the student(s)

_____ Asked the student to stop

_____ Told a school staff member

___ Ignored the student(s)

_____ Stayed with a group

_____ Other: _____________________

___ Walked away

TO BE COMPLETED BY ADMINISTRATOR

Follow up required by administrator/comments:

_______________________________________________________________________________________________________________________________

Substantiated as Bullying? ____Yes _____No If no, why (conflict, one-time incident, etc.)?___________________________________________________

Date the incident was substantiated as bullying (if applicable): _________________

Witness Notes:

Type of Substantiated Bullying:

Verbal ___ Social/Relational ___ Written Communication/Electronic ___ Physical___

Investigative Checklist:

____ Counselor/social worker involved (Name: ___________________ Date of Involvement: _________________)

____ Alleged bully’s parents notified (Name: _____________________ Date Contacted: ____________________ Phone / Email / Other)

____ Target’s parents notified (Name: ______________________ Date Contacted: ___________________ Phone / Email / Other)

____ Law enforcement notified if necessary (Date of Involvement: _________________)

____ Log entry for alleged bully

____ Log entry for target

Administrator Signature: _____________________________________________ Date: ________________

Bullying Incident Reporting Form

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