Harassment, Intimidation And Bullying/cyber Bullying Reporting Form

Shoreline   S chool   D istrict  

Harassment,   I ntimidation   a nd   B ullying/Cyber   B ullying   R eporting   F orm  

 

Directions:   P lease   c omplete   t his   f orm   a nd   r eturn   i t   t o   t he   S chool   A dministrator.   P lease   n ote   t hat   n o   d isciplinary   a ction  

can   b e   t aken   a gainst   a n   a lleged   a ggressor   b ased   s olely   o n   a nonymous   r eporting.  

 

Aggressor(s):    

Targeted   S tudents(s):    

Reporting   P erson   ( optional):  

 

Your   e mail   a ddress   ( optional):  

 

Your   p hone   n umber   ( optional):    

Name   o f   s chool   a dult   y ou   h ave   a lready   c ontacted   ( if   a ny):    

On   w hat   d ate(s)   d id   t he   i ncident(s)   o ccur   ( if   k nown)?  

 

Date   t his   f orm   w as   s ubmitted:  

 

Where   d id   t he   i ncident(s)   o ccur?   C heck   a ll   t he   a pply:  

 

☐ Classroom    

☐   L ocker   R oom  

☐   S chool   B us  

☐   D uring   S chool   A ctivity  

☐   H allway  

☐   S port(s)   F ield  

☐   I nternet  

☐   O ff   S chool   P roperty  

☐   R estroom  

☐   P layground  

☐   C ell   P hone  

☐   L unchroom/SAC  

 

 

☐   P arking   L ot  

☐   T o/From   S chool  

☐   O ther   ( please   d escribe):  

 

Please   c heck   t he   b ox   t hat   b est   d escribes   w hat   t he   a ggressor   d id.   C heck   a ll   t hat   a pply:  

 

☐   H itting,   k icking,   s hoving,   s pitting,   h air   p ulling   o r   t hrowing   s omething   a t   t he   s tudent  

☐   G etting   a nother   p erson   t o   h it   o r   h arm   t he   s tudent  

☐   T easing,   n ame   c alling,   m aking   c ritical   o r   t hreatening   r emarks   ( in   p erson,   b y   p hone,   v ia   e mail,   e tc.)  

☐   P utting   t he   s tudent   d own   a nd   m aking   t he   s tudent   a   t arget   o f   j okes  

☐   M aking   r ude   a nd/or   t hreatening   g estures  

☐   S preading   h armful   r umors   o r   g ossip  

☐   C yber   b ullying   ( calling,   t exting,   e mail,   s ocial   m edia,   e tc.)  

☐   O ther   ( please   d escribe)  

 

Why   d o   y ou   t hink   t hat   t he   h arassment/intimidation/bullying   o ccurred?    

 

 

 

Were   t here   a ny   w itnesses?   ☐   Y es  

☐   N o  

 

If   y es,   p lease   p rovide   n ames:   _ _________________________________________________________________________________________  

 

Did   p hysical   i njury   r esult   f rom   t his   i ncident?   ☐   Y es   ☐   N o  

 

If   y es,   p lease   d escribe:   _ ________________________________________________________________________________________________  

 

Was   t he   t arget   a bsent   f rom   t he   s chool   a s   a   r esult   o f   t his   i ncident?   ☐   Y es  

☐   N o  

 

If   y es,   p lease   d escribe:   _ ________________________________________________________________________________________________  

 

Is   t here   a ny   a dditional   i nformation?    

 

 

 

Thank   y ou   f or   r eporting  

 

REV0716TS