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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.)

1. 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). 2. Cyberbullying – is bullying that takes place over digital devices like cell phohes, computers, and tablets. Cyberbullying can occur through texting, apps, or on line 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. 3. 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. 4. 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.

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

  * Please enter first name.
 * Please enter last name.
 * Please enter a phone number.
 * 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)  

 * Please enter victim's first name
 * Please enter victim's last name
 * Please enter age
 * Please Select victim's school

Alleged Witness(es) (if known)  

Alleged Offender(s) (If known) 

 * Please enter offender's first name.
Please enter offender's last name.
Please enter Age.
Yes No

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

 *Please answer the question.
Actions/comments related to the student's race/ethnicity
Actions/comments related to the student's national origin.
Actions/comments related to the student's religion
Actions/comments related to the student's sex
Actions/comments related to the student's Immigration status
Actions/comments related to the student's family/parental or marital status
Actions/comments related to the student's socio-economic status
Actions/comments related to the student's academic performance
Actions/comments related to the student's perceived sexual orientation
Actions/comments related to the student's gender expression
Actions/comments related to the student's gender identity
Actions/comments related to the student's disability
Actions/comments related to the student's physical appearance
Demeaning behavior to impress others
Demeaning behavior just to be mean
An act or threat of retaliation
Gang related/gang recruitment
Human trafficking/prostitution recruitment
Any bullying, harassment, or intimidation that involves physical aggression
Cyberbullying (social media, text messages, etc.)
Teasing, name-calling, making critical remarks
Demeaning or making the student the target of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Intimidating, extorting, exploiting the student
Getting another person to target or demean the student
Spreading hurtful rumors or gossip
Racial/ethnic harassment
Sexual Harassment
Other

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

 *Can you please answer the question.
 * 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

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)

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


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!