DIRECTIONS: Complete this form if you are a student victim, the parent/guardian of a student victim, a close adult relative of a student victim, bystander, or a school staff member and wish to report an incident of alleged bulling, harassment or intimidation. Contact the school for additional information or assistance at any time. Bulling, harassment, or intimidation are serious and will not be tolerated.

This form is to be confidentially maintained in accordance with the Safe Schools Reporting Act of 2005, Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g. For more information, please see Board Policy JICK - Bullying, Harassment, · or Intimidation of Students and Administrative Regulation JICK-RA; JBA - Discrimination-Students and Administrative Regulation JBA-RA; and Board Policy JBB - Sex-Based Discrimination-Students and Administrative Regulation JBB-RA.

DEFINITIONS:

Bullying - Unwanted, demeaning behavior among students that involves a real or perceived power imbalance. The behavior is repeated, or is highly likely to be repeated, over time. To be considered bullying, the behavior must meet the bullying, harassment, or intimidation four-part test, set forth in Maryland law, and must be intentional and include: (1) an imbalance of power (students who bully use their physical, emotional, social or academic power to control, exclude, or harm others), and (2) repetition (bullying behaviors happen more than once or are highly likely to be repeated based on evidence gathered).

Bullying, Harassment, or Intimidation Four-Part Test: For the purposes of [Board Policy JICK] and in accordance with Maryland law, bullying, harassment, or intimidation is intentional conduct, including verbal, physical, or written conduct, or an intentional electronic communication, that:

Creates a hostile educational environment by substantially interfering with a student's educational benefits, opportunities, or performance, or with a student's physical or psychological well-being and is:

Either:

i. Motivated by a student's actual or a perceived personal characteristic(s); or
ii. Sexual in nature, including descriptions or depictions of a student their intimate parts exposed or engaged in an act of sexual contact; or
iii. Threatening or seriously intimidating; and

Either:
i. Occurs on school property, at a school-sponsored activity or event, or school bus; or
ii. Substantially disrupts the orderly operation of a school.
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:

ALLEGED TARGETED STUDENT:
* School:
Last Name: First Name:
Middle Name: Age:
Days Absent:

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

Alleged Witness(es) (if known):
Last Name First Name Age School *Is a Student?
1st
2nd
3rd

Alleged Offenders: (Please enter 'Unknown' in Last Name field if you don't know the offender's name)
Last Name First Name Age Sch # School *Is a Student? *Days Absent due to incident
1st
2nd
3rd
4th
5th

*Where did the incident happen? (Place an X next to the statement(s); choose all that apply)

*Place an X next to the statement(s) that best describes what happened (choose all that apply):

Describe the incident(s), including what the alleged offender(s) said or did.

Why do you think the bullying, cyberbullying, harassment, and/or intimidation occurred?
If you think the alleged motive of the bullying, harassment, or intimidation was motivated by actual or perceived personal characteristics including race, ethnicity, color, ancestry, national origin, nationality, religion, sex, sexual orientation, gender, gender identity, gender expression, marital status, pregnancy or parenting status, family structure, ability (cognitive, social/emotional, and physical), veteran status, genetic information, age, immigration or citizenship status, socioeconomic status, language, or any other legally or constitutionally protected attributes or affiliations, please provide detailed information below.


*Did a physical injury result from this incident? Place an X next to one of the following:  

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

*Was the student victim absent from school as a result of the incident?                
   *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? Place an X next to one of the following:  

Is there any additional information you would like to provide?


Submit Report  Cancel

*Required fields

Copyright © 2024 ITD/BCPS.