Bullying Reporting and Incident Form

BULLYING REPORTING AND INCIDENT FORM

As used in the School Bullying Prevention Act, "harassment, intimidation, and bullying" means any gesture, written or verbal expression, electronic communication or physical act that a reasonable person should know will harm another student, damage another student's property, place another student in reasonable fear of harm to the student's person or damage to the student's property, or insult or demean any student or group of students in such a way as to disrupt or interfere with the school's educational mission or the education of any student. Harassment, intimidation, and bullying are repeated, intentional behaviors which include, gestures or written, verbal, or physical acts, or electronic communications. Such behavior is specifically prohibited. Policy FCND
Today's Date:

MonthDayYear
Date
School Site:
Information of the Informant
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What best describes your role?

Other
Incident Details

Please be as detailed as possible while completing the following fields.
Name and grade-level of student victim(s):
Example: John Doe, 4th grade
Date of the Incident:

MonthDayYear
Date
Approximate time of the Incident:
If there were multiple occurrences, please provide additional dates and times below:
Name, grade-level, and school site of alleged offender(s), if known:
Example: John Doe, 4th grade, Piedmont Elementary
Type of Bullying (check all that apply):

Other
If other, please describe:
Where did the bullying take place? (check all that apply)

Other
If other, please describe location of the bullying incident(s):
What did the alleged offender(s) say or do to the victim(s)? Please describe in detail.
Did physical injury result from this incident?
If medical attention was required, please describe:
Was the victim absent from school as a result of this incident?
If yes, please indicate the number of days the victim was absent from school:
Is there any additional information you would like to provide?
Who has the victim spoken to regarding this incident? (check all that apply):

Other
NOTE:

The school district is not authorized to disclose to a victim, private educational or personnel data regarding an alleged perpetrator who is a student or employee of the school district. School officials will notify the parent(s) or guardian(s) of students involved in a bullying incident and the remedial action taken, to the extent permitted by law, based on a confirmed report.
I hereby certify that, to the best of my knowledge, the provided information is true and accurate.
Should be Empty:

BULLYING REPORTING AND INCIDENT FORM

Information of the Informant

Incident Details

NOTE: