Bullying Reporting Form

Directions: Bullying and intimidation are serious and will not be tolerated. This is a form to report alleged bullying and intimidation that occurred on school property; at a school-sponsored event off school property; on a school bus; or on the way to and/or from school. Please complete this form and return it to the Principal OR Guidance Counselor.

According to HMS’s student handbook, bullying includes physical intimidation, taunting, hazing, name calling, insulting, cursing, gesturing, or verbally abusing any person and/or group. HMS also prohibits Internet bullying (also referred to as cyber- bullying).

Today’s date: ______Name of student victim (person being bullied):______

Name of Person Reporting Incident (optional): ______

Name(s) of alleged bully

On what date(s) did the incident happen? ______

Where did the incident happen (choose all that apply)? On school property At a school-sponsored activity/event off school property On a school bus On the way to / from school Other (please describe):

Place an next to the statement(s) that best describes what happened (choose all the apply) Hitting, kicking, shoving, spitting, hair pulling, or throwing something Getting another person to hit or harm the student Teasing, name-calling, making critical remarks, or threatening, in person or by other means (including electronic methods) Demeaning and making the student the victim of jokes Making rude and/or threatening gestures Excluding or rejecting the student Intimidating, extorting, or exploiting Spreading harmful rumors or gossip Other (specify):

What specifically did the alleged offender(s) say or do? (Attach a separate sheet if necessary):

Is there any additional information you would like to provide? (Attach a separate sheet if necessary):

For office use only: Reviewed by: Date: Investigation Notes: