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Directions: Bullying, harassment, and intimidation are serious and will not be tolerated. This is a form to report allegedbullying harassment, or intimidation that occurred during the current school year on school property, at a schoolsponsoredactivity or event off school property, on a school bus, on the way to and/or from school*, or on the internetsenton or off school property; or that substantially disrupted the orderly operation of the school. Bullying, harassmentand intimidation includes any intentional conduct, including verbal, physical or written conduct, or an intentionalelectronic communication, that creates a hostile educational environment by substantially interfering with a student’seducational benefits, opportunities or performance, or with a student’s physical or psychological well-being. (Definitionsfor Bullying, Cyberbullying, Harassment, and Intimidation are provided below.)1. Bullying – A pattern or behavior when a person repeatedly uses power in an intentional manner, including verbal,physical, or written conduct or intentional electronic communication against one or more students. 2. Cyberbullying –The use of electronic communication to harm or harass others in a deliberate, repeated, and hostile manner.3. Harassment – Includes actual or perceived negative actions that offend, ridicule, or demean another individual withregard to race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physicalattributes, socioeconomic status, familial status, physical or mental ability, or disability. 4. Intimidation – subjecting anindividual to intentional action that seriously threatens and induces a sense of fear and/or inferiority.Conduct that is of a sexual nature is generally thought to mean actions, language, or visual materials which specificallyrefer to, portray, or involve sexual activity or language. Conduct of a sexual nature may include overt sexualsolicitations, inappropriate touching, sexual jokes, and inquiries about a person's sex life. Sexual harassment is thebroader term that encompasses conduct of a sexual nature such as unwelcomed sexual advances, requests for sexualfavors, and other verbal or physical contact of a sexual nature. Sexual harassment also includes acts that are not overtlysexual but rather are directed at individuals based on their gender such as profanity or rude behavior that is genderspecific.If you are a student, the parent/guardian of a student, a close adult relative of a student, or a school staff member andwish to report an incident of alleged bullying harassment, or intimidation, complete this form and return it to theprincipal at the student victim’s school. You may contact the school for additional information or assistance at any time.
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