EXHIBIT
STUDENT BULLYING / HARASSMENT /
INTIMIDATION
COMPLAINTS ALLEGING BULLYING, HARASSMENT
OR INTIMIDATION OF STUDENT
Bullying is defined as repeated acts over time that involves a real or perceived imbalance of power with the more powerful child or group attacking those who are less powerful. Bullying can be physical in form (e.g., pushing, hitting, kicking, spitting, stealing) verbal (e.g., making threats, taunting, teasing, name-calling) or psychological (e.g., social exclusion, spreading rumors, manipulating social relationships).
School _________________________________ Date of Report __________
Name of Student ______________________________ Grade ____________
Date(s) of Bullying Incident(s) ________________________________________
Location of Bullying Incident(s) _______________________________________
Name(s) of those who are accused of bullying student ____________________
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Witnesses if any __________________________________________________
Description of bullying: (Describe the incident, the background to the incident and any attempts you have made to problem).
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The projected solution:
Indicate what you think can and should be done to solve the problem.
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Person making report:
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Print Name Signature
If other than student - relationship to student _________________________
phone number(s) _____________________________
Report reviewed by ______________________________ on _______________
Individuals Interviewed:
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Notes: __________________________________________________________
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Signature
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