Bullying, Harassment or Intimidation Reporting Form

Directions: Bullying, harassment, and intimidation are serious and will not be tolerated. This is a form to report alleged bullying, harassment, or intimidation that occurred during the current school year on school property, at a school-sponsored activity or event off school property, on a school bus, on the way to and/or from school, or on the internet-sent on or off school property; or that substantially disrupted the orderly operation of the school. Bullying, harassment and intimidation includes any intentional conduct, including verbal, physical or written conduct, or an intentional electronic communication, that creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities or performance, or with a student’s physical or psychological well-being. (Definitions for 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 with regard to race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, physical or mental ability, or disability. 4. Intimidation – subjecting an individual 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 specifically refer to, portray, or involve sexual activity or language. Conduct of a sexual nature may include overt sexual solicitations, inappropriate touching, sexual jokes, and inquiries about a person's sex life. Sexual harassment is the broader term that encompasses conduct of a sexual nature such as unwelcomed sexual advances, requests for sexual favors, and other verbal or physical contact of a sexual nature. Sexual harassment also includes acts that are not overtly sexual but rather are directed at individuals based on their gender such as profanity or rude behavior that is gender-specific.

If you are a student, the parent/guardian of a student, a close adult relative of a student, or a school staff member and wish to report an incident of alleged bullying, harassment, or intimidation, complete this form and submit. You may contact the school for additional information or assistance at any time.

School System : Harford County Public School

Person Reporting Incident

First Name * Please enter first name.

Last Name * Please enter last name.

Telephone * Please enter a phone number.

E-mail * Please enter a valid email.

Please select description. Please select the appropriate description: *

Student

Parent/Guardian of a Student

Close Adult Relative of a Student

School Staff

Bystander

Incident

Alleged Targeted Student(s) Information

First Name * Please enter victim's first name

Last Name * Please enter victim's last name

Age * Please enter age

School * Please Select victim's school

Alleged Offender Information

First Name * Please enter offender's first name.

Last Name Please enter offender's last name.

Age Please enter Age.

School

Is he/she a student?

Yes No

Witness Information (if known)

First Name

Last Name

Age

School

On what date(s) did the incident happen? * Please select date of incident.

Check all boxes that describe what happened: *Please answer the question.

Check all boxes that describe incident location:

On school property

On the way to/from school

On a school bus

Off school property or at a school-sponsored activity or event

Digital device on school property

Digital device off school property

During virtual learning

Other (please specify)

If the incident happened on school property, please select school

Describe the incident(s), including what the alleged offender(s) said or did. *Can you please answer the question.

Why did the bullying, harassment or intimidation occur? * Can you please answer the question.

Did a physical injury result from this incident?

Yes, but it did not require medical attention Yes, and it required medical attention No

If there was a physical injury, do you think there will be permanent effects?

Yes No

Was the student victim absent from school as a result of the incident?

Yes No

If yes, how many days was the student victim absent from school as a result of the incident? (only enter a numerical value)

Did a psychological injury result from this incident?

Yes, but psychological services have not been sought
Yes, and psychological services have been sought
No

Provide additional information here:

By entering my name in this box, I acknowledge that the information in the above report is true and accurate, and that this electronic signature has the same meaning as my handwritten signature.

Signature: * Signature is Reqiured!

Date: * Signature Date is Reqiured!