Harassment or Intimidation Reporting System

Version en español

PERSON REPORTING INCIDENT:

Last Name:

First Name:

Telephone:

A confirmation email will be sent to your email address:

*Select the appropriate box:

Student

Student (Witness/Bystander)

Parent/guardian

Close adult relative

School Staff

STUDENT VICTIM:

* School:	School is required.
Last Name:	Student last name is required.	First Name:	Student first name is required.
Middle Name:		Age:	Student age is required. Please enter valid age

*On what date did the incident happen? (mm/dd/yyyy)

Open the calendar popup.

Alleged Witness(es) (if known):

	Last Name	First Name	Age	School
1st
Age must be a numeric value.
2nd
Age must be a numeric value.
3rd
Age must be a numeric value.

Alleged Offenders: (Please enter 'Unknown' in Last Name field if you don't know the offender's name)
*Where did the incident happen (choose all that apply)?

On school Property

At a school-sponsored activity or event off school property

On a school bus

On the way to/from school

Via Internet- sent off school property

Via Internet- sent on school property

*Check the boxes that best describe what happened (choose all that apply):

Any bullying, harassment, or intimidation that involves physical aggression

Getting another person to hit or harm the student

Teasing, name-calling, making critical remarks, or threatening, in person or by other means

Demeaning and making the victim of jokes

Making rude and/or threatening gestures

Excluding or rejecting the student

Intimidating (bullying), extorting, or exploiting

Spreading harmful rumors or gossip

Related to the student’s disability

Related to the student’s perceived sexual orientation

Gang related

Gang recruitment

Human trafficking/Prostitution recruitment

Racial Harassment

Sexual Harassment

Sexual in nature

Cyber bullying (e.g. social media including Facebook, Instagram, etc.)

Electronic Communication (specify)

Other (specify)

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

*Why did the harassment or initimidation (bullying) occur?

*Did a physical injury result from this incident? Please select one of the following:

Yes, but it did not require medical attention

Yes, and it required medical attention

*If there was a physical injury, do you think there will be permanent effects?

Yes

*Was the student victim absent from school as a result of the incident?

Yes

*If yes, how many days was the student victim absent from school as a result of the incident?
*Did a psychological injury result from this incident? Please select one of the following:

Yes, but psychological services have not been sought

Yes, and psychological services have been sought

Is there any additional information you would like to provide?

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*Required fields