Report Bullying Today's Date St. David School(s): (check all that apply) Elementary Middle/High School Person Reporting Incident Name Telephone Number Email Address Are you Chose the appropriate box Student Parent School Staff Bystander Name of the student victim(s): Grade Name of alleged offender(s): Grade Name of alleged witness(es): Grade On what date(s) did the incident happen? Where did the incident take place? (Choose all that apply) On school property On the school bus Via internet - sent on/off school property Is there physical injury as a result of this incident? No Yes, but no medical attention required Yes, it required medical attention* *Please provide any medical documentation and photos, if applicable. Check the statement(s) that best describe what happened Any bullying, harassment, or intimidation that involved physical aggression Teasing, name calling, making critical remarks or threatening, in person or by other means. Demeaning and making the victim of inappropriate jokes Making threatening gestures Extorting or exploiting another student Insults related to a student's disability Insults related to a student's perceived religious or sexual orientation Cyberbullying (e.g. texting, email, etc.) Gang related or recruitment Human trafficking Racial harassment Sexual harassment or inappropriate conduct Describe the incident Include what the alleged offender(s) said or did. Why do you think the incident occurred? Was the student absent as a result of the incident? Yes No If yes, how many days? Any additional detail that may be useful:
