Bullying Form
The HCPS Code of Conduct defines Bullying as: A person is being bullied or victimized when he or she is exposed repeatedly and over time to negative actions on the part of one or more persons. The three main components of bullying are aggressive behavior that involves unwanted negative actions, a pattern of behavior repeated over time and an imbalance of power or strength . The different forms of bullying are verbal, social exclusion or isolation, physical, lies and rumors, money or possessions taken or damaged, being threatened or forced to do things, racial bullying, sexual bullying and cyber bullying via cell phone or internet.
The person who inflicts such activity upon another or others is considered the bully and will be disciplined accordingly.
Source: Henrico County 2011-2012 Student Code of Conduct
Person making referral:
Today's Date:
MM
/
DD
/
YYYY
Student Victim
*
Homeroom teacher:
Location of incident:
Date of incident:
MM
/
DD
/
YYYY
Check the appropriate boxes:
saying hurtful, unpleasant things or using mean, hurtful nicknames
deliberately excluding another child(ren) from an activity or group of friends
hit, kick, pull hair, push - any physical aggression
tell lies, spread false rumors about student
Additional Information:
Image Verification
Please enter the text from the image
:
[
Refresh Image
] [
What's This?
]
Powered by
EMF
Form Builder
Report Abuse
EMF Form Builder
EMF Form Builder