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Bullying, Harassment, or Intimidation Reporting Form

About this Form

Form number: 230-35

Audience:  Parents/Guardians, Public, School Staff, Students, Teachers

Last revised: July 2017

Related Forms

Form 230-36 - Bullying, Harassment, or Intimidation Incident School Investigation Form

DIRECTIONS: Bullying, harassment, or intimidation are serious and will not be tolerated. 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 additional information 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:

(1) Either (a) motivated by an actual or perceived personal characteristic including race, ethnicity, color, ancestry, national origin, religion, immigration status, sex, gender, gender identity, gender expression, sexual orientation, family/parental status, marital status, age, physical or mental disability, poverty and socioeconomic status, or language, or other legally or constitutionally protected attributes or affiliations; or (b) threatening or seriously intimidating; and

(2) Either (a) occurs on school property, at a school-sponsored activity or event, or on a school bus; or (b) substantially disrupts the orderly operation of a school.

Cyberbullying is a form of bullying, harassment, and intimidation. “Cyberbullying” means a communication transmitted by means of an electronic device and includes the use of social media sites. Cyberbullying shall include any future applications that fall under “electronic communication.” “Electronic communication” means a communication transmitted by means of an electronic device, including a telephone, cellular phone, computer, or tablet.

Adobe PDF Bullying, Harassment, or Intimidation Reporting Form129 KEnglish
Adobe PDF Formulario para Reportar Acoso Escolar, Hostigamiento o Intimidación428 KSpanish
Adobe PDF Formulaire pour Signaler la Brimade, le Harcèlement, ou l’Intimidation40 KFrench
Adobe PDF Đơn Báo Cáo Các Hành Động Bắt Nạt, Quấy Nhiễu hay Hăm Dọa89 KVietnamese
Adobe PDF 霸凌、騷擾或恐嚇事件報告表609 KChinese
Adobe PDF 약자 괴롭히기/왕따, 희롱 및 협박 행위 보고서460 KKorean
Adobe PDF የጉልበተኝነት፣ ትንኮሳ፣ ወይም የማስፈራራት ሁኔታ ሪፖርት ማቅረቢያ ቅጽ64 KAmharic

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