JICK-EA 

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

 

____no action (unfounded)
____warning
____parent notification/conference
____detention
____suspension
____police involvement
____refer to mediation, counseling, SAP
____Tier 2 Intervention
____other: _______________________