September 8th, 2010
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USD 266 Bullying Incident Report Form


The Board of Education prohibits bullying in any form on school property, in a school vehicle, or at a school-sponsored activity or event.


"Bullying" means:

Any intentional gesture or any intentional written, verbal, or physical act or threat that is sufficiently severe, persistent, or pervasive that creates an intimidating, threatening or abusive educational environment for a student or staff member that a reasonable person, under the circumstances, knows or should know will have the effect of:




 

1. Harming a student or staff member, whether physically or mentally;
2. Damaging a student's or staff member's property;
 3. Placing a student or staff member in reasonable fear of harm to the student or staff member; or
4. Placing a student or staff member in reasonable fear of damage to the student's or staff member's property; or

 

5. Cyberbullying which means bullying by use of any electronic communication device through means including, but not limited to, e-mail, instant messaging, text messages, blogs, mobile phones, pagers, online games and Web sites.


School Districts are required by Federal Law and K.S.A. 72-6214 to protect the privacy rights of students under the age of 18.  

To report a bullying incident, please complete this form.


Items denoted with a red asterisk * are required.
 * Name of student target (victim)
 
First Name
M.
Last Name
 * Where does he/she attend school?
 
Has the appropriate teacher/coach/bus driver been contacted?
 
 
 
If yes, please provide the name(s) of who you contacted:
 
 
Name(s) of alleged bully(ies) (if known):
 * On what date(s) did the incident happen?
 
Click to View Date Picker
 * Where did the incident happen? Please choose all that apply:
 
If you selected other, please specify:
 
 * Please select the statement(s) the best describe what happened. Please choose all that apply:
 
If you selected other, please specify:
 
 * What did the alleged bully(ies) say or do?
 
 * Why did the harassment or intimidation (bullying) occur?
 
Were there any witnesses?
 
If yes, please provide their names:
 
Did a physical injury result from this incident?
 
If yes, please describe:
 
Was the victim absent from school as a result of the incident?
 
If yes, please describe:
 
Is there any additional information you would like to provide?
 
Name of person reporting (optional)
 
Today's Date
 
Click to View Date Picker
Email (optional)
 
Phone Number (optional)
 
 -  - 
(XXX)-XXX-XXXX
 
 
BULLYING INCIDENTS CAN BE REPORTED ANONYMOUSLY.