ࡱ> nqmg bjbjVV 4|r<r<e$$~~~~~8Nbbbbz]______x!*$_~"_~~bz't111d~b~z]1]111bp|$'F1I01$m$1$~11__D$$ D: Harassment, Intimidation, Bullying, and Cyberbullying Behavior Checklist Directions: In accordance with the provisions of Act 755 of the 2010 Legislative Session, this form is to be used to document the details of each reported incident of harassment, intimidation, and bullying that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; or on the way to and/or from school. It also is to be used to address cyberbullying. Todays Date: ____/____/____ School Name: __________________ District: _______________ Date of incident: _____/_____/____Time of incident_____________ Name of student target (victim) _______________________ Age: __________ Grade: __________ Ethnic origin of victim_____________________________ ( Male ( Female Name(s) of alleged perpetrator(s)AgeMale FemaleEthnic origin Indicate type of incident: ( Harassment ( Intimidation ( Bullying ( Cyberbullying Check all items below that apply: Verbal PhysicalName-callingKickingTaunting/ridiculingHitting/punchingMockingPushingMaking offensive commentsPinchingTeasingStalkingDemeaning commentsInappropriate touchingOther (please state)Other (please state) EmotionalElectronic Aggression (Cyberbullying)Offensive graffitiOffensive text messagesExcluding from groupOffensive e-mailsSpreading rumorsSending degrading imagesBeing forced to do something against his/her willPosting rumors or lies about someone Taking possessions/moneyAssuming a persons electronic identity with the intent of causing harmOther (please state) Other (please state) Where did the incident happen (choose all that apply)? ( Classroom ( Lunchroom ( School Bus ( Locker Room/Area ( Restroom ( Hallway ( Bus Stop ( Parking Lot ( On the way to/from school ( Playground ( Internet ( Cell Phone ( At a school sponsored activity or event off school property ( Other (please specify) ____________________________________________________________________ Were there any witnesses? (Yes (No If yes, please provide their names: ____________________________________________________ __________________________________________________________________________________ Physical evidence, if available: Graffiti _____ Notes _____ E-mail _____ Web sites _______ Video/audio tape _____ Other ________________________ If you feel the incident was in any way motivated by any of the following please indicate by checking where appropriate. ( Appearance (Disability (Home circumstances ( Gender (Race/ethnic origin ( Medical condition (Religion (Sexual Orientation (Other (explain) ___________________________________________________________________ Is there any other relevant information that you would like to provide?  Action taken Non-disciplinary InterventionsDisciplinary InterventionsStudent counsellingTemporary removal from the classroomParent conferenceDenial of privilegesMediationDetentionReferral to disciplinarianIn-school suspensionOut-of-school suspensionExpulsionLegal action Have you had contact with the victims parent/guardian? (Yes (No Have you had contact with the perpetrators parent/guardian? (Yes (No Have you reported this incident to any other agencies? 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