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Bullying and Harassment Concerns

Bullying and Harassment Concerns

Bullying and Harassment Reporting and Investigation Form

The official form for reporting allegations of bullying and harassment within the School District of Philadelphia.

SECTION I: GENERAL INFORMATION
From: *
Please insert your email above
Your name: *
Your telephone: *
Your role: Student     School staff     Parent/Guardian     Other     *
VICTIM INFORMATION
Alleged victim's name: *
School: *
Grade: *
Age: *
Race: *
Sex: Female     Male     Other     *
ACCUSED INFORMATION
Accused person's name:
Accused person's school: *
Accused person's grade: *
Accused person's age:
Accused person's race:
Accused person's sex: Female     Male     Other     *
Additional accused person(s):
List name, school, grade, age, race, and sex if there are more accused
If identity of accused person(s) is unknown, explain:
SECTION II: DESCRIBE THE INCIDENT
When did the incident occur? Date: *
When did the incident occur? Time:
Where did the incident occur? Location: bus
hallway
classroom
lunchroom
recess
community
internet
other
*
Was the behavior based on: race     ethnicity     national origin     gender/sex     sexual orientation     color     disability    
Which statement(s) best describe what happened Bullying, harassment or intimidation that involves physical aggression
Intimidating, extorting or exploiting
Spreading harmful rumors/gossip
Getting another person to hit/harm
Making rude and/or threatening gestures
Teasing, name calling, making critical remarks, demeaning or making jokes
Excluding or rejecting
Electronic communication
Other
*
Did a physical injury result from the incident? *
Did a psychological injury results from this incident? *
Was the alleged victim absent from school as a result of the incident? Yes     No     *
Witness name: *
Witness role: Student     School staff     Other     *
Witness school: *
Witness grade:
Additional witnesses:
List name, school, and grade if there are more witnesses
Please describe the incident: *