Montgomery County Cyberbullying/Bullying Task Force - Horsham ...

BULLYING BEHAVIOR
DATES OF BULLYING _______________
LOCATIONS OF ACTIONS________________________
________________________________________________________________________________________
TYPE OF BULLYING (check all that apply)
PHYSICAL (hitting, kicking, etc.)
VERBAL (teasing, name calling, etc.)
EMOTIONAL/EXCLUSION (starting rumors, telling others not to be friends with someone, etc.)
CYBER-BULLYING (using an electronic medium to engage in any bullying behavior)
DESCRIBE THE BULLYING INCIDENT
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Did a physical injury result from this incident? (Yes) (No)
Did the victim receive medical attention? (Yes) (No)
Was the student victim absent from school as a result of the incident? (Yes) (No)
If yes, how many days was the student victim absent from school as a result of this incident? _____
Did the victim experience psychological distress resulting from this incident? (Yes) (No)
If yes, were mental health services sought? (Yes) (No)
REPORTER SIGNATURE ______________________________ DATE OF REPORT ________________
RECEIVED BY ADMINISTRATION
ADMINISTRATOR SIGNATURE________________________________ DATE____________________
PRINTED NAME______________________________________________
TITLE____________________
Did the bullying behavior disrupt the school environment? (Yes) (No)
Conclusion/Resolution BULLYING of incident_____________________________________________________________
INCIDENT NARRATIVE CONTINUATION
_________________________________________________________________________________________
_________________________________________________________________________________________
21