USD 470
Report of Bullying Form

USD 470 Board of Education Policy JDDC prohibits bullying in any form on school property, in a school vehicle or at a school-sponsored activity or event. Students who have been subjected to bullying should immediately report bullying incidences to the appropriate authority which may include any USD 470 staff member including certified or non-certified personnel, building administration, or district administration. Once a report of bullying has been made to a USD 470 staff member, appropriate reporting and investigation will pursue. Students who have bullied others in violation of this policy may be subject to disciplinary action, up to and including suspension and expulsion. If appropriate, students who violate the bullying prohibition shall be reported to local law enforcement.

Nature of Complaint: I believe that I or someone I know has been subjected to bullying in the following form(s):

Physical Bullying (persistent pushing/shoving, making threats, defacing property, stealing, etc...)

Emotional Bullying (persistent name calling, teasing, insulting, harassing phone calls, etc...)

Social Bullying (persistent gossiping, teasing about looks, excluding someone from groups, arranging public humiliation, etc...)

Cyber-Bullying (persistent texting/messaging threats, posting defamatory Web sites, e-mailing derogatory photos, etc...)

 

Who was the person(s) engaging in bullying?

Who was the person(s) being bullied?

When did the incident occur?

Where did the incident occur? What school do those involved attend?

Please describe, to the best of your ability, the bullying incident or act:

What effect did the incident have on you?

Were there any witnesses to this incident? Yes No

If so, who?

What action do you believe the school should take with regard to this incident?

What is your name? (optional) Contact Information?

If this matter proceeds to a formal hearing, will you appear and testify as to your knowledge of the matter? Yes No