<p> L1/L2 – place in OBPP mailbox L/3 see administrator Sand Creek Middle School Bullying Incident Form Student Name: Grade/Section Date:</p><p>Staff Member Subject/Activity Time (Period)</p><p>Please check if applicable Location: Witnessed by me Reported to me by student(s) </p><p>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</p><p>Followed up with Reporting Staff Member Followed up with homeroom/team teachers </p><p>Name of OBPP Staff Member Date: Notes on Incident: (Be specific) </p><p>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</p><p>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</p><p>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. </p>