Alleged Victim *

First Name

Last Name

Where did the bullying occur? *

At the lockers

In the classroom

During lunch

During PE

When switching classes

In the bathrooms

At dismissal

At EDP

Other

Describe the Misconduct (check all that apply) *

Physical (pushing, hitting, deliberate blocking, stealing or damaging belongings on purpose)

Verbal (teasing, laughing at, name calling, making derogatory hurtful remarks, threatening words)

Visual (hurtful gestures, eye rolling, snickers, written words or pictures to harass/bully)

Social/Relational (leaving someone out on purpose, exclusion, spreading false/malicious rumors, gossiping/revealing personal information and embarrassing/humiliating another person)

Cyber-bullying (use of email, cell phone, chat rooms, text messaging, web pages/websites, instant messaging, social networking sites, blogs, video/digital photo images to harass/bully another student)

Sexual (using sexual innuendos, jokes, rumors, gossip or abusive remarks, making sexual advances/requests)

Retaliation (any form of harassment/bullying against a person who reports, testifies, assists or participates in the reporting process)