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Bullying, Harassment or Intimidation Reporting Form

Directions: Bullying, harassment, and intimidation are serious and will not be tolerated. This is a form to report alleged 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 on the internet-sent on or off school property; or that substantially disrupted the orderly operation of the school. Bullying, harassment and intimidation includes any 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. (Definitions for Bullying, Cyberbullying, Harassment, and Intimidation are provided below.)

1. Bullying – A pattern or behavior when a person repeatedly uses power in an intentional manner, including verbal, physical, or written conduct or intentional electronic communication against one or more students. 2. Cyberbullying – The use of electronic communication to harm or harass others in a deliberate, repeated, and hostile manner. 3. Harassment – Includes actual or perceived negative actions that offend, ridicule, or demean another individual with regard to race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, physical or mental ability, or disability. 4. Intimidation – subjecting an individual to intentional action that seriously threatens and induces a sense of fear and/or inferiority.

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 return it to the principal at the student victim’s school. You may contact the school for additional information or assistance at any time.

Today's Date:   School:
Person Reporting Incident Name:  
Telephone:   E-mail:  
Please select the appropriate description:

1. Name of student victim: Age: School:
     
2. Name(s) of alleged witness(es)(if known): Age: School:
 
3. Name(s) of alleged offender(s)(if known): Age: School: Is he/she a student
     
4. On what date(s) did the incident happen?

5. Check the box next to the statement(s) that best describes what happened (choose all that apply):

















6. Where did the incident happen (choose all that apply)?



*Will be collected unless specifically excluded by local board policy

7. Describe the incident(s), including what the alleged offender(s) said or did.  

8. Why did the bullying, harassment or intimidation occur?  

9. Did a physical injury result from this incident?

10. If there was a physical injury, do you think there will be permanent effects?

11. Was the student victim absent from school as a result of the incident?
 

12. Did a psychological injury result from this incident?

13. Is there any additional information you would like to provide?

Signature:    

Entering my name in this box, I hereby acknowledge that the information I have provided above is, to my knowledge, accurate. I also acknowledge that by providing my name in this box, this electronic signature has the same meaning as my handwritten signature.


 
 
 
 
 
 
 
 
 
 
Maryland State Department of Education in accordance with the Safe Schools Reporting Act 2005 7-14