EmailMe Form - NCS Bullying or Harassment Reporting Form

NCS Bullying or Harassment Reporting Form

Harassment and intimidation (bullying) means conduct, including verbal conduct, 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 motivated by an actual or a perceived personal characteristic such as race, national origin, marital status, sex, sexual orientation, gender identity, religion or disability, or is threatening or seriously intimidating.

Today's Date: *
MM / DD / YYYY
Person Reporting Incident:
Name *
First Last
Phone
### - ### - ####
Email *
I am a: *
If you marked "other" please explain
Incident Report
Name of student victim: *
First Last
School Division of Student Victim *
Lower School (K-4)
Middle School (5-8)
Upper School (9-12)
Name(s) of alleged offender(s) (If known):
First Last
Name(s) of alleged offender(s) (If known):
First Last
Name(s) of alleged offender(s) (If known):
First Last
Grade level of alleged offender(s)
Grade level of alleged offender(s)
Grade level of alleged offender(s)
On what date(s) did the incident happen?
MM / DD / YYYY
MM / DD / YYYY
MM / DD / YYYY
MM / DD / YYYY
Where did the incident happen? *

On school property Outside of school At a school-sponsored activity Other

Choose all that apply
Please specify specific location: *
Please mark the statement(s) that best describes what happened. Choose all that apply. *
Hitting, kicking, shoving, spitting, hair pulling, or throwing something
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
Other
If "other" please specify:
What did the alleged offender(s) say or do? *
Why did the harassment or intimidation (bullying) occur?
Did a physical injury result from this incident? *
No
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
No
Was the student victim absent from school as a result of the incident? *
Yes
No
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? *
No
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?
Student Signature
Clear
Date
MM / DD / YYYY
Parent Signature
Clear
Date
MM / DD / YYYY
If you have documentation, please include here.

	On school property	Outside of school	At a school-sponsored activity	Other
Choose all that apply

Person Reporting Incident:

Incident Report