Challenger Intermediate School

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Bullying Incident Report Form

What is Bullying?

2013 Legislature amended the anti-bullying statute (KSA 72-8256) and became effective July 1, 2013. The Goddard USD 265 Board of Education revised and adopted policy on August 12, 2013 aligned to KSA 72-8256, which can be found at USD 265 BOE Policies.

1) Bullying means: a) any intentional gesture or any intentional written, verbal, electronic or physical act or threat either by any student, staff member or parent towards a student or by any student, staff member that is sufficiently severe, persistent, or pervasive that such gesture, act or threat creates an intimidating, threatening or abusive educational environment that a reasonable person, under the circumstances, knows or should know will have the effect of:

Harming a student or staff member, whether physically or mentally;
Damaging a student or staff member in reasonable fear of harm to the student or staff member; or
Placing a student or staff member in reasonable fear of damage to the student’s or staff member’s property;
Cyberbullying; or
Any other form of intimidation or harassment prohibited by the board of education of the school district in policies concerning bullying adopted pursuant to this section or subsection of K.S.A. 72-8205 and amendments thereto.

What is Peer Conflict?

Peer conflict is when two (2) students with no perceived imbalance of power argue, disagree, or fight. Conflict resolution or peer mediation may be more appropriate.

Please Fill Out The Bullying Incident Report Form Below

After reading the definition of bullying and peer conflict, would you consider this to be-

Bullying

Peer Conflict

First Name of Student Target (Victim)

Middle Initial of Student Target (Victim)

Last Name of Student Target (Victim)

Where does he/she attend school?

Has the appropriate staff member been contacted?

Yes

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?

If you selected other, please specify:

Please select the statement(s) the best describe what happened. Please choose all that apply:

Reaquired field: Hitting, kicking, shoving, spitting, hair pulling, or throwing something

Reaquired field: Getting another person to hit or harm the student

Reaquired field: Teasing, name calling, making demeaning remarks, jokes, or threatening in person or by other means

Reaquired field: Making rude and/or threatening gestures

Reaquired field: Excluding or rejecting the student

Reaquired field: Intimiditing, extorting, or exploiting

Reaquired field: Spreading harmful rumors or gossip

Reaquired field: Harassment (Sexual/Racial/Physical)

Reaquired field: Other

If you selected other, please specify:

What did the alleged bully(ies) say or do?

Are you a witness to this incident?

Yes

Were there other witnesses?

Yes

If yes, please provide their names:

Is there any additional information you would like to provide?

Name of Person Reporting

Email Address

Phone Number

Email a copy to

optional

Required Fields

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