WAELDER ISD ADMINISTRATIVE

BULLYING INCIDENT REPORT FORM

Completion of this form is necessary for reported instances on the campus of bullying. This form

Is to be completed by the campus administrator and a copy sent to the Superintendent.

Person Bullying:______Grade:______Date:______

Please list the following:

Name of the person reporting bullying
Date the report of bullying was made
Date you interviewed the student being bullying
Date you interviewed the student bullying

List the name of all possible witnesses:

List the name of all witness you interviewed:

Please complete the following steps in order to determine if bullying has occurred. Bullying occurs only if you answer yes to at least one question in Steps A-E and can prove such justification.

Describe the conduct that occurred that is alleged to have been bullying.

Does the above-described incident meet the following criteria? If yes continue to Step B. If no, then no bullying occurred.

YES / NO
Written expression
Verbal expression
Expression through electronic means
Physical contact

Describe where and when the alleged incident occurred: (be as specific as possible)

Was the above location in one of the following places? If yes, continue to Step C. If no, the no bullying occurred.

YES / NO
On school property
At a school sponsored activity
At a school related activity
In a vehicle operated by the District

STEP C

Does the conduct described above meet any of the following criteria? If you answer yes to at least one question, move to the next question. If you answer no to all of the questions, no bullying occurred.

YES / NO
Has the effect of physical harming a student
Will have the effect of physically harming a student
Damaging a student’s property
Placing a student in reasonable fear of harm to the student’s person
Placing a student in reasonable fear of damage to the student’s property
Is sufficiently severe enough that the action creates an intimidating educational environment for a student
Is sufficiently persistent enough that the action creates an intimidating educational environment for a student
Is sufficiently pervasive enough that the action creates an intimidating educational environment for a student
Is sufficiently severe enough that the threat creates an intimidating educational environment for a student
Is sufficiently persistent enough that the threat creates an intimidating educational environment for a student
Is sufficiently pervasive enough that the threat creates an intimidating educational environment for a student
Is sufficiently severe enough that the actions creates a threatening educational environment for a student
Is sufficiently persistent enough that the action creates a threatening educational environment for a student
Is sufficiently pervasive enough that the action creates a threatening educational environment for a student
Is sufficiently severe enough that threat creates a threatening educational environment for a student
Is sufficiently persistent enough that the treat creates a threatening educational environment for a student
Is sufficiently severe enough that the action creates an abusive educational environment for a student
Is sufficiently persistent enough that the action creates an abusive educational environment for a student
Is sufficiently pervasive enough that the action creates an abusive educational environment for a student
Is sufficiently severe enough that the threat creates an abusive educational environment for a student
Is sufficiently persistent enough that the threat creates an abusive educational environment for a student
Is sufficiently pervasive enough that the threat creates an abusive educational environment

What are the facts that support your responses checked yes?

STEP D

Does the activity above meet any of the following criteria? If yes to at least one question, please justify your response below and then move to the next Step. If you answered no to all of the questions, bullying did not occur.

YES / NO
Conduct exploits an imbalance of power between the student perpetrator and the student victim through written expression
Conduct exploits an imbalance of power between the student perpetrator and the student victim through verbal expression
Conduct exploits an imbalance of power between the student perpetrator and the student victim through physical conduct

What are the facts that support your responses checked yes?

STEP E

Does the activity above meet any of the following? If you answer yes to at least one question, please justify your response below and then move to the next Step. If you answer no to all of the questions, bullying did not occur.

YES / NO
Interferes with a student’s education
Substantially disrupts the operation of a school

What are the facts that support your responses checked yea?

If you have answered in at least one box in steps A-E and provided facts to support the appropriate answers, then bullying has occurred. If bullying has occurred, move to Step F. if no bullying has occurred, move to step G.

STEP F

Please identify each person you made aware of the bullying incident (parents, teachers, administration, etc.)

DATE / TIME / METHOD / NAME OF PERSON / POSITION OF PERSON

Please list all steps taken to remediate the bullying situation.

STEP G

Some student misconduct that falls under a school’s anti-bullying policy may also trigger responsibilities under one or more of the federal antidiscrimination laws enforced by the Education Department Office for Civil Rights (OCR). The school may become aware of misconduct through a report of bullying that may trigger an investigation that could lead to the discovery of additional incidents that, taken together, may constitute a hostile environment.

Did the conduct contain any of the following?

YES / NO
Discrimination on the basis of race
Discrimination on the basis of color
Discrimination on the basis of national origin
Discrimination on the basis of sex
Discrimination on the basis of disability
Was the harassment sufficiently serious that it created a hostile environment

If you answered yes to any of the above questions, describe how the conduct is related to any of the items in Step G. if you answered no to all of the questions in Step G, move to Step H.

STEP H

Harassment does not have to include intent to harm, be directed at a specific target, or involved repeated incidents. Harassment creates a hostile environment when the conduct is sufficiently severe, pervasive, or persistent so as to interfere with or limit a student’s ability to participate in or benefit from the services, activities, or opportunities offered by a school. When such harassment is based on race, color, national origin, sex, or disability, it violates the civil rights laws that the OCR enforces.

Did the conduct meet any of the following criteria?

YES / NO
Was the conduct encouraged?
Was the conduct tolerated?
Was the conduct inadequately addressed by school employee?
Was the conduct ignored by school employee?

If you answered yes to any of the above questions, describe how the conduct is related to any of the items in Step H. if you answered no to all the questions in Step G and H, then no harassment occurred.

If you have answered yes in at least on box in steps G OR H and provided facts to support the appropriate answers, the harassment has occurred. If harassment has occurred, please contact the Superintendent immediately to begin an investigation. Law Enforcement should be contacted id the educator becomes aware of:

  • Death threats or threats of other forms of violence to a person or property
  • Excessive intimidation or extortion
  • Threats or intimidation that involve any form of bias or discrimination
  • Any evidence of sexual exploitation

Completed by:
______
Print Name Print Title Date
Signature of person completing the report