Bully Incident Form (514. Policy) Date of Incident:(Required) Time of Incident: Hours : Minutes AM PM AM/PM Repeat Infraction?(Required) Yes No Location of Incident (check all that apply):(Required) Hallway Restroom Classroom Gym Lunch Room Playground Locker Room Bus Stop On the Bus Parking Lot To/From School After School Program School Sponsored Event Text/Phone/Internet/Social Media Other Name of Victim(s):(Required)Name of Student(s) Bullying:(Required)Name(s) of Witnesses/Bystanders:(Required)Type of Bullying:(Required) Verbal Physical (if selected, complete the "Physical Bullying Section") Relational Physical Bullying Section (complete this section, if you answered "Yes" as to the type of bullying being "Physical" above)Did the Physical Bullying Result in Injury?(Required) Yes No Was the Physical Bullying Reported to the Nurse?(Required) Yes No Was the Physical Bullying Reported to the Police?(Required) Yes No Bullying Behaviors (check all that apply):(Required) Shoved/Pushed Hit, Kicked, Punched Threatened Stole/Damaged Posessions Excluded Taunting/Ridiculing Writing/Graffiti Told Lies/False Rumors Staring/Leering Intimidating/Extortion Demeaning Comments Inappropriate Touching Cyber-bullying Using Text Messages Cyber-bullying Using a Website Cyber-bullying Using E-mail Cyber-bullying Using Other Means Racial Bullying (please complete next question) Sexual Bullying (please complete next question) Disability Bullying (please complete next question) If you answered "Racial, "Sexual, "Religious, and/or "Disability" to the previous question, please describe:Reported to the school by (check all that apply):(Required) Teacher Student Bystander Victim/Target Parent Bus Driver Other Physical Evidence(Required) Notes Graffiti Video/Audio Website None Other Describe the Incident:(Required)Today's Date:(Required) Reported By:(Required)Who would you like this form submitted to?(Required)Scott Fitzsimonds - SuperintendentShelby Nosan - PreK - 12 PrincipalSam Lyon - Dean of StudentsEmail Address of the Person Completing this Form:(Required) Signature(Required)Your NameYour NameYour NameYour NameActions Taken (for office use only, see Protocol for Guidelines)Consequences:Remediation:Referral for Additional Support Services:Parent Contact (for office use only)Date: Time: Hours : Minutes AM PM AM/PM Person Making Contact:Result:CAPTCHA
