Bullying, Harassment or Intimidation Reporting Form

Directions:
The Bullying, Harassment or Intimidation Reporting Form should be used to report alleged incidents of 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 through electronic communication on or off school property. School staff will address incidents that occur at school or have a connection or nexus back to the school setting that create a risk of harm to other students while they are at school or interfere with the educational environment.  If you are a student, the parent/guardian or caregiver of a student, a close adult relative of a student, a school staff member, or a bystander and wish to report an incident of alleged bullying, cyberbullying, harassment, or intimidation, please complete this form, and return it to the school principal.  You may contact the school for additional information or assistance at any time. (Bullying, cyberbullying, harassment, and intimidation definitions are provided below.)

Definitions:

Bullying– is unwanted, demeaning behavior among students that involves a real or perceived power imbalance. The behavior is repeated, or is highly likely to be repeated, over time. In order to be considered bullying, the behavior must be intentional and include: 1) An imbalance of power (students who bully use their physical, emotional, social, or academic power to control, exclude, or harm others), and 2) Repetition (bullying behaviors happen more than once or are highly likely to be repeated based on evidence gathered).

Cyberbullying– is bullying that takes place over digital devices like cell phones, computers, and tablets. Cyberbullying can occur through texting, apps, or online via social media, forums, or gaming where people can view, participate in, or share content. Cyberbullying includes sending, posting, or sharing negative, harmful, false, or hurtful content about another student. It can include sharing personal or private information about someone else causing embarrassment or humiliation.

Harassment– includes actual or perceived negative actions that offend, ridicule, or demean another student with regard to race, ethnicity, national origin, immigration status, family/parental or marital status, sex, sexual orientation, gender identity, gender expression, religion, ancestry, physical attributes, socioeconomic status, physical or mental ability, or disability.       

Intimidation – is any communication or action directed against another student that threatens or induces a sense of fear and/or inferiority. Retaliation may be considered a form of intimidation.

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 alleged offender's first name.

Last Name Please enter alleged 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 targeted student absent from school as a result of the incident?

Yes No

If yes, how many days was the targeted student 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!