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Bullying, Harassment, or Intimidation Reporting Form

This form is to be confidentially maintained in accordance with the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g.

Directions: Bullying, harassment, or intimidation are serious and will not be tolerated. This is a form to report alleged bullying, harassment, or intimidation that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; or on the way to and/or from school*, in the current school year. If you are a student victim, the parent/guardian of a student victim, a close adult relative of a student victim, or a school staff member and wish to report an incident of alleged bullying, harassment or intimidation, complete this form and return it to the Principal at the student victim’s school. Contact the school for additionalinformation or assistance at any time.

Bullying, harassment, or intimidation means 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 and is:

  • motivated by an actual or a perceived personal characteristic including race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, or physical or mental ability or disability; or,
  • threatening or seriously intimidating; and,
  • occurs on school property, at a school activity or event, or on a school bus; or,
  • substantially disrupts the orderly operation of a school.
“Electronic communication” means a communication transmitted by means of an electronic device, including a telephone, cellular phone, computer, or pager.

PDF Size
Form Number
Bullying, Harassment, or Intimidation Reporting Form English 152 K 230-35
ለበጣም ዝብዘባ ወይም ዛቻ፣ ማዋከብ ወይም ማስፈራራት ሁኔታ ሪፖርት የሚደረግበት ቅጽ Amharic 173 K 230-35 Amharic
欺凌、騷擾或恐嚇事件報告表 Chinese 362 K 230-35 Chinese
Brimade, Harcèlement, ou Intimidation Formulaire de Rapport French 174 K 230-35 French
약자 괴롭히기/왕따, 희롱 및 협박 행위 보고서 Korean 205 K 230-35 Korean
Formulario Para Reportar Casos de Amenaza, Acoso o Intimidación (“bullying”) Spanish 38 K 230-35 Spanish
Đơn Báo Cáo Các Hành Động Bắt Nạt, Quấy Nhiễu hay Hăm Dọa Vietnamese 655 K 230-35 Vietnamese

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat

For questions regarding forms, call Harriet Potosky at (301) 279-3538.

Updated August 19, 2013 | Maintained by Missy Gumula
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