Bullying and Harassment Anonymous Reporting Form
Bullying and Harassment Anonymous Reporting Form

Lee County School District 

Bullying, Harassment, or Intimidation Reporting Form 

Note: Fields marked with an * are required

Bullying, harassment, or intimidation means intentional conduct, including verbal, physical, or written conduct, or an intentional electronic communication, that creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities, or performance, or with a student’s physical or psychological well-being.  It is motivated by an actual or a perceived personal characteristic including race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attribute, socioeconomic status, familial status or physical or mental ability or disability.  It is the behavior of threatening or seriously intimidating; and occurs on school property, at a school activity or event, or on a school bus; or substantially disrupts the orderly operation of a school. 

The definitions for Bullying, Cyberbullying, Harassment, and Intimidation are provided below:
1. Bullying – Intentional conduct, including verbal, physical, or written conduct, or an intentional electronic communication that creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities, or performance, or with their physical or psychological well-being. 

2. Cyberbullying – The use of electronic communication (transmitted by means of an electronic device, including a telephone, cellular phone, computer, or pager) to harass, humiliate, intimidate, and/or threaten others. 

3. Harassment – A sufficiently severe action or persistent, pervasive pattern of actions or statements, directed at an identifiable individual or group, that is intended to be, or which a reasonable person would perceive as, ridiculing or demeaning. 

4. Intimidation – subjecting an individual to intentional action that seriously threatens and induces a sense of fear and/or inferiority.

The conduct must (1) be motivated by an actual or a perceived personal characteristic including race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, or physical or mental ability or disability, or (2) be threatening or seriously intimidating. Sexual discrimination includes sexual harassment, sexual assault and sexual violence and is characterized as unwelcome conduct of a sexual nature that interferes with a student’s ability to learn. This term is generally thought to mean actions, language or visual materials that specifically refer to, portray or involve sexual activity or language.  Conduct of a sexual nature may include overt sexual solicitations, inappropriate touching, sexual jokes and inquiries about a person’s sex life.  Sexual harassment is the broader term that encompasses conducts of a sexual nature such as unwelcome sexual advances, requests for sexual favors, and other verbal or physical contact of a sexual nature.  Sexual harassment also includes acts that are not overtly sexual but rather are directed at individuals based on their gender such as profanity or rude behavior that is gender-specific.

If you are a student, the parent/guardian of a student, a close adult relative of a student, or a school staff member and wish to report an incident of alleged bullying harassment, or intimidation, please complete and submit the form below.  You may contact the school for additional information or assistance at any time.

Today's date: *

School of Alleged Victim: *

Person Reporting Incident 

 

Name of Student/Victim:

Student/Victim's Age:

Alleged Offenders Information (If known) Please Enter Name(s), Age(s) and School: *

Alleged Witnesses Information (If known) Please Enter Name(s), Age(s) and School:

On what date did the incident occur? *

Where did the incident happen (Choose all that apply): *

Select the statement that best describes what happened (Choose all that apply): *

Describe the incident(s), including what the alleged offender(s) said or did: *

Why did the bullying, harassment or initimidation occur?

Did a physical injury result from this incident? *

Was the student victim absent from school as a result of the incident?

Is there any additional information you would like to provide?

 



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