PIKE ROAD SCHOOLS-BULLYING REPORT FORM

Pike Road Schools has established a process for students, parents, guardians, and bystanders to report instances of bullying to the school administrator for further review and investigation in order to minimize antisocial behavior in the school environment. The school will be notified about bullying if this form is completed. Any reported bullying incident may be investigated, and disciplinary action will be taken if deemed necessary (Patriot Code of Conduct code 2.02).

Bullying: A continuous pattern of intentional behavior by the same person and/or persons (this is not a one-time event), whether physical, verbal, written, or electronic, that is intended to annoy, intimidate, extort, alarm, or terrorize one or more students. Characteristics of bullying include the following categories: gender, sexual orientation, age, religion, nationality, ethnicity, race, color, socioeconomic background, mental, physical, or sensory disability.

Hazing: Any willful action taken in connection with initiation into or affiliation with any organization. This prohibited conduct could include annoying, teasing, or belittling behavior that causes a student to be alarmed or terrorized. This prohibited conduct also includes but is not limited to, sexually graphic gestures, jokes, writings, or comments.

Harassment: The intentional pursuit of a pattern of conduct intended to annoy, intimidate, extort, alarm, or terrorize another individual, whether physical, verbal, written, or electronic. In addition, the behavior threatens the health, safety, or welfare of students, staff, or others on school grounds, in school vehicles, at designated bus stops, and at school-sponsored events, whether on or off campus.

REPORTER INFORMATION

Your First Name *

Your Last Name *

You are a *

Phone Number

Email Address

Have you filed a report before about this bullying incident? *

Did you reach out to a staff member at Pike Road Schools regarding this matter? *

If you answered yes to the previous question, please provide the name of the staff member you had a conversation with.

INCIDENT INFORMATION

Please choose the school that is associated with the incident. *

What is the date of the most recent incident? * +

Name of victim(s) *

Name of alleged aggressor *

Please provide information on the location of the incident. *

Please provide the names of any witnesses. *

Please specify the type of incident. *

Behavior is related to *

Student's perceived sexual orientation or gender identity

Student's religious beliefs

Student's racial or cultural background

Student's disability

Other: Other:

Please describe the incident and include as much detailed information as possible. *

Did a physical injury occur from this incident? *

Did the victim miss school due to the incident? *

Signature of reporter

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Moderate physical contact (such as shoving or pushing)	Severe physical contact (such as hitting or kicking)
Stalking (in person or online)	Teasing/name calling/demeaning jokes
Verbal intimidation	Inappropriate gesturing
Theft	Exclusion/rejection
Destruction of property	Sexual contact
Verbal harassment	Spreading rumors
Threats	Electronic communications (texts, sexts, emails, etc.)
Public humiliation/ridicule	Other Other