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Report Bullying
Harassment, Intimidation and Bullying Report
By submitting this form you acknowledge that the information entered is complete, true, and accurate.
Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.
Your Information (optional)
First Name:
Last Name:
E-Mail:
Phone #:
Address:
City:
State:
Zipcode:
Incident Information
When did this incident happen?
Location of Incident:
Select a School
Please select school
Churubusco Elementary School
Churubusco Jr-Sr High School
Precise Location
Unknown
Bus
Hallway
Classroom
Locker room
Gym
Cafeteria
Extracurricular activity
Bathroom
At lockers
Playground
Other
Your Role:
Select Your Role
Please tell us who you are
Student
Teacher
Staff Member
Administrator
Parent
Volunteer
Bystander
Other
Type of harassment, intimidation, bullying or harm:
Types of Harassment, Intimidation and Bullying
Physical involves hurting a person’s body or possessions. Physical includes:
Hitting/kicking/pinching
Spitting
Tripping/pushing
Taking or breaking someone’s things
Making mean or rude hand gestures
Verbal is saying or writing mean things. Verbal includes:
Teasing
Name-calling
Inappropriate sexual comments
Taunting
Threatening to cause harm
Social, sometimes referred to as relational, involves hurting someone’s reputation or relationships. Social includes:
Leaving someone out on purpose
Telling other children not to be friends with someone
Spreading rumors about someone
Embarrassing someone in public
Cyberbullying is bullying that takes place using electronic technology. Examples of cyberbullying include:
Mean text messages or emails
Rumors sent by email or posted on social networking sites
Embarrassing pictures, videos, websites, or fake profiles
More information at
stopbullying.gov
Cause of harassment, intimidation, bullying or harm:
Unknown
Age
Color
Race
Creed
National Origin
Ancestry
Marital Status
Sex
Religion
Gender Identity
Physical Attributes
Physical/Mental Abilities
Political Belief
Political Party Preference
Socioeconomic Status
Sexual Orientation
Family Status
Other
Method of harassment, intimidation, bullying or harm:
Unknown
Electronic Communication
Written Communication
Verbal
Physical
Social/Relational
Other
What is the victims age/or grade?:
Who was the person being harassed, intimidated bullied or harmed?:
What is the offenders age and/or grade?:
Who was harassing, intimidating, bullying or causing harm?:
Select Offender Type
Unknown
Student from the same district
Student from a different district
Certified staff
Volunteer
Other
Description:
By submitting this form you acknowledge that the information entered is complete, true, and accurate. Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.
By checking this box you agree to the above disclaimer.