DIRECTIONS
HOW TO USE FORM

Bullying, harassment, and intimidation are serious and will not be tolerated. This is a form to report alleged bullying harassment, or intimidation that occurred during the current school year:

  • on school property
  • at a school-sponsored activity
  • at an event off school property
  • on a school bus
  • on the way to and/or from school*
  • on the internet-sent on or off school property
  • that substantially disrupted the orderly operation of the school.

Bullying, harassment and intimidation mean any 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. 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.

Electronic communication means communication transmitted by means of electronic device, including a telephone, cellular phone, computer and pager. Conduct that is of a sexual nature is the most commonly reported form of sexual harassment. This term is generally thought to mean actions, language or visual materials which 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 unwelcomed 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, complete this form and return it to the Principal at the student victim’s school. You may contact the school for additional information or assistance at any time.



HOW TO USE FORM
  • Enter as much information on the form as possible.
  • After submitting the form, you will receive a confirmation number.
  • An email notification will be immediately sent to the school specified as the victim's school.
  • If you provide your email address, you will receive a confirmation email.
  • This form has been tested with Internet Explorer 8, 9, and 10, Chrome and Firefox but if you experience technical difficulties, you may contact BCPS Technology Support Services at 443-809-4672 from 7am - 4pm Monday - Friday.
  • Specific questions about this form may be directed to the Office of School Safety at 443-809-4360.
11/20/2018
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PERSON REPORTING INCIDENT



If you provide an email address, you will receive a confirmation email

 
1
NAME OF ALLEGED STUDENT VICTIM
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2
NAME(S) OF ALLEGED WITNESS(ES) (IF KNOWN)

First Name Last Name Age School
select
Add a witness
3
NAME(S) OF ALLEGED OFFENDER(S) (IF KNOWN)

First Name Last Name Age School Student?
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Add an offender
4
ON WHAT DATE(S) DID THE INCIDENT HAPPEN?



 
5
CHECK THE STATEMENT(S) THAT DESCRIBES WHAT HAPPENED (CHECK ALL THAT APPLY)
 
6
WHERE DID THE INCIDENT HAPPEN? (CHECK ALL THAT APPLY)



 
7
DESCRIBE THE INCIDENT(S), INCLUDING WHAT THE ALLEGED OFFENDER(S) SAID OR DID.

8
WHY DID THE BULLYING, HARASSMENT OR INTIMIDATION OCCUR?

ADDITIONAL INFORMATION (INJURIES, ETC)
9. Did a physical injury result from this incident? Select one of the following:
10. If there was a physical injury, do you think there will be permanent effects?
11. Was the student victim absent from school as a result of the incident?
12. Did a psychological injury result from this incident? Select one of the following:
13. Is there any additional information you would like to provide?

11/20/2018






 
Maryland State Department of Education in accordance with the Safe Schools Reporting Act of 2005
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