Bullying Incident Report

Bullying Incident Report
"Bullying" means the intentional harassment, intimidation, humiliation, ridicule, defamation, or threat or incitement of violence on a continuous basis, if an incident is repeated or has the potential to be repeated, over time by a student against another student or public school employee by a written, verbal, electronic, or physical act that causes or creates actual or reasonably foreseeable:

1. Physical harm to a public school employee or student or damage to the public school employee's or student's property;

2. Substantial interference with a student's education or with a public school employee's role in education;

3. A hostile educational environment for one (1) or more students or public school employees due to the severity, persistence, or pervasiveness of the act; or

4. Substantial disruption of the orderly operation of the school or educational environment.
Name of Reporter*

First NameLast Name
Email Address of Reporter*

Confirmation Emailexample@example.com
Phone Number of Reporter*
Please enter a valid phone number.
Name(s) of Reported Victim(s):*
School Building of Reported Victim(s):*
Name of Reported Bully:*

First NameLast Name
Name(s) of Witnesses:*
Date of Incident:*
Location of Incident:*
Was an adult informed?*

YesNo
If yes, what is the name of the adult that was informed?
Type of Bullying: (Check all that apply)*

PhysicalVerbalWrittenSocial / RelationalCyberbullyingOther
Did the bullying result in an injury?*

YesNo
Detailed Description of Incident (Please be as specific as possible):*
Has this affected the victim’s willingness to attend school?*

YesNo
If yes, please describe:
Describe any changes in the victim’s grades or willingness to participate in activities at school.*
Describe how this situation has affected the learning environment.*
Has this occurred previously with this offender?*

YesNo
If you answered yes to the question above, please answer the questions below.
Where did it occur?
Which LHSD staff member was it reported to?
Thank you for taking the time to report this incident. School administration takes all reports of concerning behavior seriously. While not every incident meets the formal definition of bullying, any behavior that is inappropriate or disruptive to the school environment is addressed in accordance with school policies to support the safety and well-being of all students.
Should be Empty: