Sand Creek Middle School

L1/L2 – place in OBPP mailbox L/3 see administrator Sand Creek Middle School Bullying Incident Form Student Name: Grade/Section Date:

Staff Member Subject/Activity Time (Period)

Please check if applicable Location: Witnessed by me Reported to me by student(s)

Type of Bullying Incident - Indicate Level 1 (L1) or Level 2 (L2), or Level 3 (L3) See Consequence Rubric on back of this Page Verbal Physical Social/Relational Sexual Harassment L1 Teasing L1 Pushing L1 Purposeful exclusion L2 L2 L2 L2 (telling others not be refer to social worker L3 L3 L3 someone’s friend, etc) (grade 5/6) or guidance L1 Name Calling L1 Slapping L1 Gossiping counselors (grade 7/8) L2 L2 L2 L3 L3 L3 L1 Insulting Remarks L1 Grabbing L1 Starting Rumor L2 L2 L2 L3 L3 L3 L1 Cyber-Bullying L1 Shoving L1 Spreading Rumor L2 L2 L2 L3 L3 L3

Followed up with Reporting Staff Member Followed up with homeroom/team teachers

Name of OBPP Staff Member Date: Notes on Incident: (Be specific)

L1/L2 – place in OBPP mailbox L/3 see administrator Level 1/Level 2 Bullying Key Verbal – Level One (L1) Physical – Level One (L1) Social/Relational – Level One (L1)  Teasing  Pushing  Purposeful exclusion, telling others not  Name Calling  Slapping to be someone’s friend  Insulting Remarks  Grabbing  Gossiping  Cyber-Bullying  Shoving  Starting or Spreading Rumors

Verbal – Level Two (L2) Physical – Level Two (L2) Social/Relational – Level Two (L2)  Purposely embarrassing  Threatening gestures  Purposefully embarrassing or humiliating or humiliating another  Threatening/causing physical another student student harm  Teasing publicly about clothing, looks,  Profanity  Damaging property relationships, socio-economic status  Slander  Stealing/hiding or purposely  Insulting comments about taking intelligence, size, ability, race, color, religion, ethnicity, gender Sexual Harassment – Automatic Level 2  Sexual Comments  Leering  Gestures  Actions or comments based on a person’s sexual orientation  Sexual harassment verbal and teasing in nature

Please mark location on map below, mark with an “X” where incident occurred. This will help to see if there are bullying “zones” in our school.