EmailMe Form - Middlesex County Public Schools

Middlesex County Public Schools

Bullying Report Form

BULLYING INCIDENTS CAN BE REPORTED ANONYMOUSLY.

Any intentional gesture or any intentional written, verbal, or physical act or threat that is sufficiently severe, persistent, or pervasive that creates an intimidating, threatening or abusive educational environment for a student or staff member that a reasonable person, under the circumstances, knows or should know will have the effect of:

1. Harming a student or staff member, whether physically or mentally;
2. Damaging a student's or staff member's property;
3. Placing a student or staff member in reasonable fear of harm to the student or staff member; or
4. Placing a student or staff member in reasonable fear of damage to the student's or staff member's property; or
5. Cyberbullying which means bullying by use of any electronic communication device through means including, but not limited to, e-mail, instant messaging, text messages, blogs, mobile phones, pagers, online games and Web sites.

Name of student target (victim) *
First Last
Name of victim's school:
Has this incident been reported to a school employee?
Yes
No
If yes, please provide the name(s) of who you contacted:
Incident details
Name(s) of the alleged bully/bullies (if known):
On what date did the incident happen?
MM / DD / YYYY
Where did the incident happen?
Classroom
Hallway
Restroom
Playground
Locker Room
Lunchroom
Parking Log
School Bus
Electronically
School Sponsored Activity/Event off School Property
Other
If you selected 'Other' please specify:
Please select the statement(s) that best describe what happened. Please choose all that apply.
Hitting, Kicking, Shoving, Spitting, Other Physical Contact
Getting another person to hit or harm the student
Teasing, Name calling, Making critical remarks or threatening
Demeaning and making the victim of jokes
Making rude or threatening gestures
Excluding or rejecting the student
Intimidating, Extorting or Exploiting
Spreading harmful rumors or gossip
Cyberbullying
Sexual Harrasment
Other
If you selected 'Other' please specify:
What did the alleged bully/bullies say or do?
Were there any witnesses (if known)?
Yes
No
Name(s) of witnesses:
Did a physical injury result from this incident?
Yes
No
Unknown
Was the victim absent from school as a result of the incident?
Yes
No
Unknown
Is there any additional information you would like to provide?
Name of person reporting
(OPTIONAL)
Todays Date
MM / DD / YYYY
Email (OPTIONAL)
Phone Number
(OPTIONAL):
### - ### - ####
MCPS Bullying Report
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Incident details