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Houston Elementary School
Bullying Report Form
Denison ISD prohibits bullying as defined by policy.
This conduct is considered bullying if it:
1. Exploits an imbalance of power between the student perpetrator and the student victim through written or verbal expression or physical conduct; and
2. Interferes with a student’s education or substantially disrupts the operation of a school.
To obtain assistance and intervention, any student who believes that he or she has experienced bullying or believes that another student has experienced bullying should immediately report the alleged acts to a teacher, counselor, principal, or other District employee.
Name of person filing report
(leave blank if you wish to remain anonymous)
First
Last
Email of Person Filing Report
*
Your Title/Position
*
Student
Staff Member
Parent/Guardian
Victim's Name
*
First
Last
Victim's Grade Level
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
What type of bullying is occuring?
*
Physical
Emotional
Social
Damage to property
Online
Location of Incident
*
School property
School bus
School-Sponsored activity or event off school property
On the way to/from school
Electronic media (text messages, email, social media, etc.)
Other
Date & Time of the Incident
*
MM
/
DD
/
YYYY
HH
:
MM
AM
PM
AM/PM
Offender's Names
(List all of the offenders)
*
Please describe in detail what happened.
*