Harassment, Intimidation and Bullying Report

Your Information (optional)

First Name:

Last Name:

E-Mail:

Phone #:

Address:

City:

State:

Zipcode:

Incident Information

When did this incident happen?

Location of Incident:

Your Role:

Type of harassment, intimidation, bullying or harm:

Types of Harrasment, Intimidation and Bullying

Physical involves hurting a person’s body or possessions. Physical includes:
- Hitting/kicking/pinching
- Spitting
- Tripping/pushing
- Taking or breaking someone’s things
- Making mean or rude hand gestures
Verbal is saying or writing mean things. Verbal includes:
- Teasing
- Name-calling
- Inappropriate sexual comments
- Taunting
- Threatening to cause harm
Social, sometimes referred to as relational, involves hurting someone’s reputation or relationships. Social includes:
- Leaving someone out on purpose
- Telling other children not to be friends with someone
- Spreading rumors about someone
- Embarrassing someone in public
Cyberbullying is bullying that takes place using electronic technology. Examples of cyberbullying include:
- Mean text messages or emails
- Rumors sent by email or posted on social networking sites
- Embarrassing pictures, videos, websites, or fake profiles

More information at stopbyllying.gov

Cause of harassment, intimidation, bullying or harm:

Method of harassment, intimidation, bullying or harm:

What is the victims age/or grade?:

Who was the person being harassed, intimidated bullied or harmed?:

What is the offenders age and/or grade?:

Who was harassing, intimidating, bullying or causing harm?:

Description:

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