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Bullying
BULLYING, HARASSMENT or INTIMIDATION REPORTING FORM
This form will be confidentially maintained in accordance with the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g.
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 on school property; at a school-sponsored activity or event off school property; on a school bus; or in the current school year. If you are a student victim, the parent/guardian of a student victim, a close adult relative of a student victim, 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. Contact the school for additional information or assistance at any time. Choctaw County Board of Education, 107 Tom Orr Drive, Butler, AL 36904, 205-459-3031.
DEFINITION: Bullying, harassment, and intimidation are intentional verbal, written, and/or physical conduct or an intentional electronic communication that creates a hostile educational environment by substantially interfering with a student's educational benefits, opportunities and performance, or with a student's physical or psychological well-being an dis as follows: (1) 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. (2.) Threatening or seriously intimidating, (3.) Occurs on school property, at a school activity or event, or on a school bus, and (4.) Substantially disruptive to the orderly operation of a school. "Electronic Communication" means a communication transmitted by means of an electronic device, including but not limited to telephone, cellular phone, computer or pager.
Today's Date: *
01. Name of student victim: *
Age:
Grade:
School: *



02. Name of Alleged Offender (If Known): *
Age:
Is he/she a student? *
School (If Known) *



Name of Additional Alleged Offender (If Any):
Age:
Is he/she a student?
School:



Name of Additional Alleged Offender (If Any):
Age:
Is he/she a student?
School:



Name of Additional Alleged Offender (If Any):
Age:
Ia he/she a student?
School:



03. On what date did the incident happen? *
Additional date the incident happen:
Additional date the incident happen:
04. Where did the incident happen (Choose all that apply)? *

05. Place check next to the statement(s) that best describes what happened (Choose all that apply): *







Electronic Communications or Other (Describe)
06. Did a physical injury result from this incident? *

07. If there was a physical injury, do doctors think there will be permanent effects? *
08. Was the student victim absent from school as a result of this incident? *
09. If yes, how many days was the student victim absent from school as a result of the incident?
10. Did a psychological injury result from this incident? *

11. What did the alleged offender(s) say or do? *
12. Why did the bullying, harassment or intimidation occur? *
13. Is there any additional information you would like to provide?

In accordance with the Student Harassment Prevention Act of 2009