Laurel Springs School                     

Bullying, Harassment, or Intimidation

Reporting/Investigation Form

Directions:  Complete items 1-11 and return to Ms. Westerby or Mrs. Garrett.

Today’s date:  ___________________

Person Reporting incident:  Name__________________________________________________

Person reporting is a:  (check one)

o   Student  - Grade:  __

o   Witness/Bystander – Grade:  __

o   Parent/Guardian

o   School Staff Member

1.  Name of student victim ______________________________________    Grade______

2.  Name(s)/grade of alleged offender(s) if  known:  ________________________________________________________  __________________________________________________________________________________________________

3.  Date(s) of incident(s):  ___/___/___         ___/___/___      ___/___/___

4.  Where did the incident(s) happen?  (Check all that apply)

o   On school property – state location ___________________________________________

o   At a school-sponsored activity off school property

o   On the way to/from school  (circle which)

5.  Check the statement that best describes what happened (check all that apply)

o   Any bullying, harassment, intimidation that involves physical aggression

o   Encouraging another person to hit or harm the student or to ignore or pick on the student

o   Teasing, name-calling, threatening, making critical remarks in person or by other means

o   Demeaning and making the brunt of a joke

o   Deliberately excluding or rejecting the student to be hurtful

o   Spreading harmful rumors or gossip

o   Making rude and/or threatening gestures

o   Electronic communications (specify)  _____________________________________________________________

o   Other (specify) _______________________________________________________________________________

7.  Why did the incident occur?  (circle all that apply)

Appearance                      Gender                                Sexual orientation           Gender identity                                Nat'l. origin

Religion                                Disability              Race                                      To impress others            Just to be mean

Other:  ____________________________________________________________________________________________

8.  Did a physical injury result from this incident?  (circle one)

NO                         YES, did not require medical attention                                   YES, and it required medical attention

9.  Was the victim absent from school as a result of the incident?    NO                    YES

10. Did a psychological injury result from the incident?  (circle one)

NO                         YES, psychological services have not been sought             YES, psychological services sought

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11. Is there any additional information you would like to provide?  (Attach a separate sheet if necessary)

Signature________________________________________                                  Date ____________________________

Received by______________________________________                                  Date ____________________________

INVESTIGATION

1.  What actions were taken to investigate?  (Choose all that apply)

o   Interviewed:     Victim                    Alleged Offender(s)        Witness(es)       School Nurse                Staff____________________

o   Interviewed:    Victim’s parent/guardian                               Alleged offender’s parent/guardian

o   Witness statements collected in writing – if so, attach

o   Reviewed medical information

o   Examined physical evidence

o   Obtained copy of police report

o   Other:  __________________________________________________________________________________

2.  What corrective actions were taken?  (Choose all that apply)

o   None required – this was a false allegation

o   None – the incident did not warrant any corrective action

o   Student conference                                                                                                       Date/Time:  ____________________

o   Student warning                                                                                                              Date/Time: ____________________

o   Letter of apology

o   Counseling – Specify with whom/when:  ________________________________________________________

o   Parent:                 letter                     phone call                   conference                 Date/Time:_____________________

o   Missing lunchtime recess                                                                                             Date(s):  _______________________

o   In-School suspension                                                                                                     Date(s): ________________________

o   Other (specify) ______________________________________________________________________________

3.  Additional information gained during the interview (attach a separate sheet)

DETERMINATION:  (check one)

o   Bullying

o   Conflict

o   Other ________________________________________________________________________________

Investigated by:  _________________________________     Date:  ____________________

Title:                       _________________________________

Kathleen Westerby, Principal _______________________       Date: ____________________

To Dr. Brown, Superintendent:     Date ________________