514 BULLYING REPORT FORM

BULLYING REPORT FORM

South Washington County Schools • Independent School District No. 833

 

General Statement of Policy Prohibiting Bullying

An act of bullying, by either an individual student or a group of students, is expressly prohibited on school premises, on school district property (leased or owned), at school functions or activities, or on school transportation.  This policy applies not only to students who directly engage in an act of bullying but also to students who, by their indirect behavior, condone or support another student’s act of bullying.  This policy also applies to any student whose conduct at any time or in any place constitutes bullying or other prohibited conduct that interferes with or obstructs the mission or operations of the school district or the safety or welfare of the student or other students, or materially and substantially interferes with a student’s educational opportunities or performance or ability to participate in school functions or activities or receive school benefits, services, or privileges.  This policy also applies to an act of cyberbullying regardless of whether such act is committed on or off school district property and/or with or without the use of school district resources

 

Complainant Information:

Alleged Target: ______________ Home Phone: ______________________   

Home Address: ______________________ Work Phone: _______________________     

Best time to contact: _____________  

Home:_________________________

Work:__________________________

Cell Phone:______________________      

 

 

Identifying Information: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Date: ___________ Location:_________________

 

Alleged Bully or Bullies:      

Names of Bystanders:      

 

 

Description of Incident

Describe the incident(s) in detail. Please include any verbal statements (i.e., threats, requests, demands, name calling) or whether any physical force or contact was involved.  Attach additional pages if necessary. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

     

Total pages submitted including this page ____ (include name and date on each page.)

 

This complaint is filed based on my belief that  ____________________________bullied me or another person.  I hereby certify that the information I have provided in this complaint is true and complete to the best of my knowledge.

 

Complainant Signature:_____________________________________  Date:__________    

Received by Signature:______________________________________  Date:_________      

 

Please return this completed form to school principal or designee.