Bullying, Harassment or Intimidation Reporting

DIRECTIONS

Bullying, harassment, and intimidation are serious and will not be tolerated. This is a form to report alleged bullying harassment, or intimidation that occurred during the current school year:

on school property
at a school-sponsored activity
at an event off school property
on a school bus
on the way to and/or from school*
on the internet-sent on or off school property
that substantially disrupted the orderly operation of the school.

Bullying, harassment and intimidation mean any intentional conduct, including verbal, physical or written conduct, or an intentional electronic communication, 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. The conduct must:

be motivated by an actual or a perceived personal characteristic including race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, or physical or mental ability or disability, or
be threatening or seriously intimidating.

Electronic communication means communication transmitted by means of electronic device, including a telephone, cellular phone, computer and pager. Conduct that is of a sexual nature is the most commonly reported form of sexual harassment. This term is generally thought to mean actions, language or visual materials which specifically refer to, portray or involve sexual activity or language. Conduct of a sexual nature may include overt sexual solicitations, inappropriate touching, sexual jokes and inquiries about a person's sex life. Sexual harassment is the broader term that encompasses conducts of a sexual nature such as unwelcomed sexual advances, requests for sexual favors, and other verbal or physical contact of a sexual nature. Sexual harassment also includes acts that are not overtly sexual but rather are directed at individuals based on their gender such as profanity or rude behavior that is gender-specific.

If you are a student, the parent/guardian of a student, a close adult relative of a student, or a school staff member and wish to report an incident of alleged bullying harassment, or intimidation, complete this form and return it to the Principal at the student victim’s school. You may contact the school for additional information or assistance at any time.

Today's Date: 9/22/2018

DIRECTIONS | HOW TO USE FORM

BALTIMORE COUNTY PUBLIC SCHOOLS

select

PERSON REPORTING INCIDENT

First Name:

Telephone:

Middle Initial:
Last Name:

Email:

If you provide an email address, you will receive a confirmation email

Check the appropriate box:

StudentParent/guardian of a studentClose adult relative of a studentSchool StaffBystander

1

NAME OF ALLEGED STUDENT VICTIM

First Name:

Age:

Middle Initial:

select

Last Name:

2

NAME(S) OF ALLEGED WITNESS(ES) (IF KNOWN)

First Name

Last Name

Age

School

select

Add a witness

3

NAME(S) OF ALLEGED OFFENDER(S) (IF KNOWN)

First Name

Last Name

Age

School

Student?

select

YesNo

Add an offender

4

ON WHAT DATE(S) DID THE INCIDENT HAPPEN?

(MM/DD/YYYY):

6

WHERE DID THE INCIDENT HAPPEN? (CHECK ALL THAT APPLY)

On school propertyOn a school bus
At a school-sponsored activity or event off school propertyOn the way to/from school *
Via Internet - sent on school propertyVia Internet - sent off school property
* Will be collected unless specifically excluded by local board policy

7

DESCRIBE THE INCIDENT(S), INCLUDING WHAT THE ALLEGED OFFENDER(S) SAID OR DID.

8

WHY DID THE BULLYING, HARASSMENT OR INTIMIDATION OCCUR?

Today's Date: 9/22/2018

I certify that the information on this form is accurate to the best of my knowledge. Quote from Theodore Roosevelt. Knowing what's right doesn't mean much unless you do what's right!

Quote from Theodore Roosevelt. Knowing what's right doesn't mean much unless you do what's right!

Signature: