Harassment, Intimidation and Bullying Report

By submitting this form you acknowledge that the information entered is complete, true, and accurate. Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.

Your Information (optional)

First Name:

Last Name:

E-Mail:

Phone #:

Address:

City:

State:

Zipcode:

Incident Information

When did this incident happen?

Location of Incident: Select a School Precise Location

Your Role: Select Your Role

Type of harassment, intimidation, bullying or harm:

Types of Harassment, Intimidation and Bullying

Physical involves hurting a person’s body or possessions. Physical includes:
- Hitting/kicking/pinching
- Spitting
- Tripping/pushing
- Taking or breaking someone’s things
- Making mean or rude hand gestures
Verbal is saying or writing mean things. Verbal includes:
- Teasing
- Name-calling
- Inappropriate sexual comments
- Taunting
- Threatening to cause harm
Social, sometimes referred to as relational, involves hurting someone’s reputation or relationships. Social includes:
- Leaving someone out on purpose
- Telling other children not to be friends with someone
- Spreading rumors about someone
- Embarrassing someone in public
Cyberbullying is bullying that takes place using electronic technology. Examples of cyberbullying include:
- Mean text messages or emails
- Rumors sent by email or posted on social networking sites
- Embarrassing pictures, videos, websites, or fake profiles

More information at stopbullying.gov

Cause of harassment, intimidation, bullying or harm:

Method of harassment, intimidation, bullying or harm:

What is the victims age/or grade?:

Who was the person being harassed, intimidated bullied or harmed?:

What is the offenders age and/or grade?:

Who was harassing, intimidating, bullying or causing harm?: Select Offender Type

Description:

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