Anne Arundel County Public Schools  |  Office of Safe and Orderly Schools
Bullying, Harassment or Intimidation Reporting Form

Directions: 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 or event off school property, on a school bus, on the way to and/or from school*, or on the internet-sent on or off school property; or that substantially disrupted the orderly operation of the school. Bullying, harassment and intimidation includes 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. (Definitions for Bullying, Cyberbullying, Harassment, and Intimidation are provided below.)

  1. Bullying - A pattern or behavior when a person repeatedly uses power in an intentional manner, including verbal, physical, or written conduct or intentional electronic communication against one or more students.
  2. Cyberbullying - The use of electronic communication to harm or harass others in a deliberate, repeated, and hostile manner.
  3. Harassment - Includes actual or perceived negative actions that offend, ridicule, or demean another individual with regard to race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, physical or mental ability, or disability.
  4. Intimidation - subjecting an individual to intentional action that seriously threatens and induces a sense of fear and/or inferiority.

Conduct that is of a sexual nature 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 conduct 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 submit it. Submitted forms will be emailed to the Principal at the student victim's school. You may contact the school for additional information or assistance at any time.

Today's date:  
6/27/2017
School System: 
Anne Arundel County Public Schools
School:         *
PERSON REPORTING INCIDENT Name: *
Telephone: * E-Mail: *
Select the appropriate box: * 
 
1. Name(s) of student victim(s):  * Age: School:  *
    
 
2. Name(s) of alleged witness(es) (If known): Age: School (If known):
    
 
3. Name(s) of alleged offender(s) (If known): Age: School (If known): Is he/she a student?
      
 
4. On what date(s) did the incident happen?:
 *
(mm/dd/yyyy)
 
(mm/dd/yyyy)
 
(mm/dd/yyyy)
 
5. Select the statement(s) that best describes what happened (choose all that apply): * [check at least one]
(specify)


















 




6. Where did the incident happen (choose all that apply)? * [check at least one]




*Will be collected unless specifically excluded by local board policy
7. Describe the incident(s), including what the alleged offender(s) said or did. *
8. Why did the bullying, harassment or intimidation occur?
9. Did a physical injury result from this incident? Check 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?  
If yes, how many days was the student victim absent from school as a result of the incident?
12. Did a psychological injury result from this incident? Check one of the following:
13. Is there any additional information you would like to provide?
Signature:  *  Date: 6/27/2017
 (Retype your name as your signature)  

By signing this report form, I attest that all information on this form is accurate to the best of my knowledge and I understand the serious nature of this report. By signing this report form, I understand and agree to be contacted by school, local, state or federal authorities to assist in the matters of this report.

Maryland State Department of Education in accordance with the Safe Schools Reporting Act of 2005
7-13



Note: A receipt copy of this form is sent to the e-mail specified at the top of page 1
and to principals/designated staff, upon Submittal.

  Upon submission, this report will be sent electronically to the principal and other designated staff of the school that you have indicated on the form. The report will then be handled in accordance with Anne Arundel County Public Schools' Board of Education Regulation JCCA-RA: Bullying/Cyberbullying/Harassment and Intimidation/Hazing/Bias Behavior.

Are you sure you want to submit the Report Form to school personnel?

Note: A receipt copy of this form is sent to the e-mail specifed at the top of page 1.
  You must fill out the following required fields:

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