Bullying, Harassment and Intimidation Incident Report Form

Directions: Bullying, harassment, or intimidation are serious and will not be tolerated. This is a form to report alleged bullying, harassment or intimidation that has occurred on school property, during a school-sponsored activity or event off school property, on school transportation, or on the way to or from school, in the current school year. If you feel you are the target of bullying, harassment or intimidation, or wish to report an incident of alleged bullying, harassment or intimidation.

Bullying Defined:

Bullying is aggressive behavior that is intentional and that involves an imbalance of power or strength. Bullying typically involves a pattern of repeated, intentional hostility and/or aggression by an individual or group toward another individual or group. Bullying is designed to disturb, threaten or upset the targeted person(s).

Bullying can be physical (i.e. hitting, damaging property), verbal (i.e. name calling), emotional (i.e. excluding, rumor spreading), or cyber (i.e. texting, e-mail, social network, cell phone).
Date Date / MM / DD YYYY
Person Reporting the Incident
Name of Reporter Name of Reporter First Last
Phone of Reporter Phone of Reporter - ### - ### ####
Email of Reporter
Check all the apply to person reporting the incident:

Check all the apply to person reporting the incident: Target Witness/Bystander Parent Guardian Staff Other Other
Details
Name of Student Target Name of Student Target First Last
Building of Student Target
Grade of Student Target
#1 Name of Alleged Offender (if known) #1 Name of Alleged Offender (if known) First Last
#1 Is Alleged Offender a Brunswick Student

#1 Is Alleged Offender a Brunswick Student Yes No
#2 Name of Alleged Offender (if known) #2 Name of Alleged Offender (if known) First Last
#2 Is Alleged Offender a Brunswick Student

#2 Is Alleged Offender a Brunswick Student Yes NO
#3 Name of Alleged Offender (if known) #3 Name of Alleged Offender (if known) First Last
#3 Is Alleged Offender a Brunswick Student

#3 Is Alleged Offender a Brunswick Student Yes NO
Date incident(s) occurred Date incident(s) occurred / MM / DD YYYY
Date incident(s) occurred Date incident(s) occurred / MM / DD YYYY
Date incident(s) occurred Date incident(s) occurred / MM / DD YYYY
Select the statement(s) the best describes what happened (check all that apply)

Select the statement(s) the best describes what happened (check all that apply) Any bullying, harassment, or intimidation that involves physical aggression Getting another person to harm the student Teasing, name-calling, making critical remarks, or threatening, in person or by other means Demeaning and making the student a target of jokes Making rude and/or threatening gestures Excluding or rejecting the student Intimidating (bullying), extorting, or exploiting Spreading harmful rumors or gossip Damaging property Cyber threats or harassment Other Other
Where did the incident happen? (check all that apply)

Where did the incident happen? (check all that apply) On school property To/From school Bus stop School sponsored event School bus Cafeteria Playground Classroom Hallway Locker Room Restroom Phone Internet Stairwell Other Other
What did the Alleged Offender do?
Did anything lead up to the bullying/harassment that may help to further explain the situation?
Has this been reported to the school before?

Has this been reported to the school before? Yes No
If yes, by whom?
If yes, when? If yes, when? / MM / DD YYYY
Did physical injury result from this incident?

Did physical injury result from this incident? No Yes, but it did not require medical attention Yes, and it required medical attention
Was the target absent from school as a result of the incident

Was the target absent from school as a result of the incident Yes No
If yes, how many days was the Target absent as a result of the incident?
Additional information you would like to provide.
Draw your signature into the box below.

Draw or Type

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Full Name

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Bullying, Harassment and Intimidation Incident Report Form

Bullying, Harassment and Intimidation Incident Report Form

Bullying Defined:

Person Reporting the Incident

Details