Sleepy Eye High School Bullying Report Form

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ISD 84 maintains a firm policy prohibiting all forms of bullying. All persons are to be treated with respect and dignity. Bullying by any pupil, teacher, administrator or other school personnel who creates an intimidating environment will not be tolerated under any circumstances.

Bullying means any written or verbal expression, physical actor or gesture, or intentional electronic communication by an individual that is intended to cause or is perceived as causing distress to another and which substantially interferes with another’s educational benefits, opportunities, and/or performance on school property, at a school sponsored event or on the bus. Bullying includes, but is not limited to, conduct by an individual or group that a reasonable person under the circumstances knows or should know has the effect of: 1. harming someone, 2. damaging of someone’s property. 3. Placing someone in reasonable fear or harm to person or property. 4. Creating a hostile educational environment. 5. Intimidating someone.

Your Name:

Today's Date:

YYYY

Name of victim:

Name of alleged offender:

Witnesses or Bystanders:

What date(s) did the incident happen?

Have you submitted a bullying report for this issue before?

Yes

Clear selection

This happens/happened:

Once

2-3 times

Daily

Clear selection

Where did the incident happen? (Check all that apply)

On school property

On the bus

School sponsored event

Electronic device

On the way to/from school

If the incident happened on school property, where specifically?

Nature of bullying being reported (check all that apply)

Physical: Acts such as hitting, spitting, kicking, or damaging your or another student’s property.

Verbal: Saying mean or hurtful things or threatening you or another student.

Social: Excluding you or a student from a group, telling peers not to talk to you or another student.

Emotional: Spreading rumors or lies about you or another student.

Cyber/Online: Occurs on website or social media, by cell phone, email or text message.

What did the alleged offender(s) say or do?

What resources/tools have you used so far to handle this specific situation? (Check all that apply)

Ignore the person/walk away

Told them to stop

Report to a teacher

Talked with your counselor about the situation

Reported to the principal

Nothing

I am submitting this form based on my belief that ____________ bullied me or another person. I am reporting this because I am concerned and I want the situation to be better in the future.

By submitting this form I certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge and belief.

Submit

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