"Bullying Incident Reporting Form - Greenfield-Central Community School Corporation"

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Greenfield-Central Community School Corporation
Bullying Incident Reporting Form
Name of Person Completing Form (may remain anonymous): _____________________________________ Date of Form Submission: __________
Definition of Bullying: "Bullying" means overt, unwanted, repeated acts or gestures, including verbal or written communications or images transmitted in any
manner (including digitally or electronically), physical acts committed, aggression, or any other behaviors, that are committed by a student or group of students
against another student with the intent to harass, ridicule, humiliate, intimidate, or harm the targeted student and create for the targeted student an objectively
hostile school environment that:
(1) places the targeted student in reasonable fear of harm to the targeted student's person or property;
(2) has a substantially detrimental effect on the targeted student's physical or mental health;
(3) has the effect of substantially interfering with the targeted student's academic performance; or
(4) has the effect of substantially interfering with the targeted student's ability to participate in or benefit from the services, activities, and privileges
provided by the school.
Date and Time of Incident(s): ___________________________ Location of Incident(s): _______________________
Student(s) Initiating Alleged Bullying: _____________________________
____________________________ ______________________________
Student(s) Affected: ________________________________
______________________________
____________________________
Student Witness(es): ________________________________ ______________________________
____________________________
Check all spaces below that apply to the alleged incidents:
______ Name calling
______ Writing / graffiti
______ Damaging property
______ Spitting
______ Shoving / pushing
______ Inappropriate touching
______ Stalking
______ Threatening
______ Intimidation / extortion
______ Demeaning comments
______ Hitting / kicking
______ Intentional exclusion
______ Inappropriate gesturing
______ Taunting / ridiculing
______ Cyberbullying / text message
______ Stealing
______ Showing a weapon
______ Other ___________________
______ Staring / leering
Background:
______ Has there been a history between the individuals?
______ Were the actions unwanted?
______ Is there an imbalance of power?
______ Were the actions deliberate and meant to harm the other student?
______ Has this or a similar incident happened before?
Describe the incident:
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Physical evidence:
______ Graffiti
_____ Websites/Social Media
_____ Text Message
______ Notes
_____ Voice Message
_____ Other: _____________________
______ Email
_____ Video Recording
Steps the student has taken to deal with the issue (choose all that apply):
___ Avoided the student(s)
_____ Asked the student to stop
_____ Told a school staff member
___ Ignored the student(s)
_____ Stayed with a group
_____ Other: _____________________
___ Walked away
TO BE COMPLETED BY ADMINISTRATOR
Follow up required by administrator/comments:
_______________________________________________________________________________________________________________________________
Substantiated as Bullying? ____Yes _____No If no, why (conflict, one-time incident, etc.)?___________________________________________________
Date the incident was substantiated as bullying (if applicable): _________________
Witness Notes:
Type of Substantiated Bullying:
Verbal ___ Social/Relational ___ Written Communication/Electronic ___ Physical___
Investigative Checklist:
____ Counselor/social worker involved (Name: ___________________ Date of Involvement: _________________)
____ Alleged bully’s parents notified (Name: _____________________ Date Contacted: ____________________ Phone / Email / Other)
____ Target’s parents notified (Name: ______________________ Date Contacted: ___________________ Phone / Email / Other)
____ Law enforcement notified if necessary (Date of Involvement: _________________)
____ Log entry for alleged bully
____ Log entry for target
Administrator Signature: _____________________________________________ Date: ________________
Greenfield-Central Community School Corporation
Bullying Incident Reporting Form
Name of Person Completing Form (may remain anonymous): _____________________________________ Date of Form Submission: __________
Definition of Bullying: "Bullying" means overt, unwanted, repeated acts or gestures, including verbal or written communications or images transmitted in any
manner (including digitally or electronically), physical acts committed, aggression, or any other behaviors, that are committed by a student or group of students
against another student with the intent to harass, ridicule, humiliate, intimidate, or harm the targeted student and create for the targeted student an objectively
hostile school environment that:
(1) places the targeted student in reasonable fear of harm to the targeted student's person or property;
(2) has a substantially detrimental effect on the targeted student's physical or mental health;
(3) has the effect of substantially interfering with the targeted student's academic performance; or
(4) has the effect of substantially interfering with the targeted student's ability to participate in or benefit from the services, activities, and privileges
provided by the school.
Date and Time of Incident(s): ___________________________ Location of Incident(s): _______________________
Student(s) Initiating Alleged Bullying: _____________________________
____________________________ ______________________________
Student(s) Affected: ________________________________
______________________________
____________________________
Student Witness(es): ________________________________ ______________________________
____________________________
Check all spaces below that apply to the alleged incidents:
______ Name calling
______ Writing / graffiti
______ Damaging property
______ Spitting
______ Shoving / pushing
______ Inappropriate touching
______ Stalking
______ Threatening
______ Intimidation / extortion
______ Demeaning comments
______ Hitting / kicking
______ Intentional exclusion
______ Inappropriate gesturing
______ Taunting / ridiculing
______ Cyberbullying / text message
______ Stealing
______ Showing a weapon
______ Other ___________________
______ Staring / leering
Background:
______ Has there been a history between the individuals?
______ Were the actions unwanted?
______ Is there an imbalance of power?
______ Were the actions deliberate and meant to harm the other student?
______ Has this or a similar incident happened before?
Describe the incident:
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Physical evidence:
______ Graffiti
_____ Websites/Social Media
_____ Text Message
______ Notes
_____ Voice Message
_____ Other: _____________________
______ Email
_____ Video Recording
Steps the student has taken to deal with the issue (choose all that apply):
___ Avoided the student(s)
_____ Asked the student to stop
_____ Told a school staff member
___ Ignored the student(s)
_____ Stayed with a group
_____ Other: _____________________
___ Walked away
TO BE COMPLETED BY ADMINISTRATOR
Follow up required by administrator/comments:
_______________________________________________________________________________________________________________________________
Substantiated as Bullying? ____Yes _____No If no, why (conflict, one-time incident, etc.)?___________________________________________________
Date the incident was substantiated as bullying (if applicable): _________________
Witness Notes:
Type of Substantiated Bullying:
Verbal ___ Social/Relational ___ Written Communication/Electronic ___ Physical___
Investigative Checklist:
____ Counselor/social worker involved (Name: ___________________ Date of Involvement: _________________)
____ Alleged bully’s parents notified (Name: _____________________ Date Contacted: ____________________ Phone / Email / Other)
____ Target’s parents notified (Name: ______________________ Date Contacted: ___________________ Phone / Email / Other)
____ Law enforcement notified if necessary (Date of Involvement: _________________)
____ Log entry for alleged bully
____ Log entry for target
Administrator Signature: _____________________________________________ Date: ________________