"Harassment, Intimidation and Bullying Incident Reporting Form - Elementary Level - Bellevue School District"

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Elementary Level
Harassment, Intimidation and Bullying Incident Reporting Form
Name of reporting person (optional): _____________________________________________________
 I don’t want to share my name
Today’s date: _________________
My school: ________________________________ Your email address (optional): _______________________________ Your phone number (optional): _____________________
Name of the student who was bullied, harassed or intimidated: ________________________________________________________________________________________________
If you told an adult at your school what happened, please give us the name of that person: __________________________________________________________________________
If you know the name(s) of the bullies or their physical description (hair color, eye color, how tall, boy or girl, grade, or what teacher do they have), please tell us the name(s):
__________________________________________________________________________________________________________________________________________________
If you know on what dates and times the incident(s) happened, please tell us: ____________________________________________________________________________________
Please check the boxes that relate to the incident:
Where did the incident happen?
What happened during the incident?
Was anybody physically hurt?
 Classroom
 School bus
 Taunting, cruelty
 Threats using gestures or remarks
 No
 Hallway
 School activity
 Teasing , name calling
 Share inappropriate images/notes
 Yes, medical attention NOT required
 Restroom
 On the way to/from school
 Intimidation, humiliation
 Harmful physical contact
 Yes, medical attention required
 Playground
 Off school property
 Retaliation
 Sexual comments or contact
Please explain: __________________
 Locker room
 Internet/Social media
 Harmful rumors or gossip
 Use others to harm a student
_______________________________
 Lunchroom
 Cell phone
 Exclusion, rejection
 Demanding money from a student
_______________________________
 Cyber bullying
 Take advantage of a student
_______________________________
 Sport field
 Other: __________________
 Parking lot
________________________
 Other: ________________________________________________
_______________________________
Was the student absent from school because of what happened?
 No
 Yes. Number of days the student was absent: ___________
Why do you think the harassment, intimidation or bullying happened? _________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Were there any witnesses?  No  Yes. If yes, please give us their names: __________________________________________________________________________________
Is there anything else you want to tell us about what happened? _____________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
For office use only
Date received: ___________________
Report received by: _____________________________________________
Name of parent/guardian contacted: _____________________________________________
Action taken: ___________________________________________________________________________________________________________________________________________________________________
Check one:
 Resolved
 Unresolved
Referred to: __________________________________________________________________________________________________________________
Elementary Level
Harassment, Intimidation and Bullying Incident Reporting Form
Name of reporting person (optional): _____________________________________________________
 I don’t want to share my name
Today’s date: _________________
My school: ________________________________ Your email address (optional): _______________________________ Your phone number (optional): _____________________
Name of the student who was bullied, harassed or intimidated: ________________________________________________________________________________________________
If you told an adult at your school what happened, please give us the name of that person: __________________________________________________________________________
If you know the name(s) of the bullies or their physical description (hair color, eye color, how tall, boy or girl, grade, or what teacher do they have), please tell us the name(s):
__________________________________________________________________________________________________________________________________________________
If you know on what dates and times the incident(s) happened, please tell us: ____________________________________________________________________________________
Please check the boxes that relate to the incident:
Where did the incident happen?
What happened during the incident?
Was anybody physically hurt?
 Classroom
 School bus
 Taunting, cruelty
 Threats using gestures or remarks
 No
 Hallway
 School activity
 Teasing , name calling
 Share inappropriate images/notes
 Yes, medical attention NOT required
 Restroom
 On the way to/from school
 Intimidation, humiliation
 Harmful physical contact
 Yes, medical attention required
 Playground
 Off school property
 Retaliation
 Sexual comments or contact
Please explain: __________________
 Locker room
 Internet/Social media
 Harmful rumors or gossip
 Use others to harm a student
_______________________________
 Lunchroom
 Cell phone
 Exclusion, rejection
 Demanding money from a student
_______________________________
 Cyber bullying
 Take advantage of a student
_______________________________
 Sport field
 Other: __________________
 Parking lot
________________________
 Other: ________________________________________________
_______________________________
Was the student absent from school because of what happened?
 No
 Yes. Number of days the student was absent: ___________
Why do you think the harassment, intimidation or bullying happened? _________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Were there any witnesses?  No  Yes. If yes, please give us their names: __________________________________________________________________________________
Is there anything else you want to tell us about what happened? _____________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
For office use only
Date received: ___________________
Report received by: _____________________________________________
Name of parent/guardian contacted: _____________________________________________
Action taken: ___________________________________________________________________________________________________________________________________________________________________
Check one:
 Resolved
 Unresolved
Referred to: __________________________________________________________________________________________________________________