WCSC Bullying Reporting Name (optional), Information, School, Date? Question Title * 1. Name (optional), Information, School, Date? Name (Optional): You are the Target or Reporter: You are a Student, Staff, Parent, Administrator: E-mail Address (Optional): Phone number (optional): Elementary, MS or HS (Specify grade): Date: Anonymous, Confidential or Non-Confidential? Question Title * 2. Anonymous, Confidential or Non-Confidential? Anonymous - Individuals may file a report without revealing their identity. No disciplinary action will be taken against an alleged aggressor based solely on an anonymous report. Possible responses to an anonymous report include enhanced monitoring of specific locations at certain times of day or increased monitoring of specific students or staff. Confidential - Individuals may ask that their identities be kept secret from the accused and other students. Like anonymous reports, no disciplinary action will be taken against an alleged aggressor based solely on a confidential report. Non-confidential - Complainants agreeing to make their complaint non-confidential will be informed that due process requirements may require that the district release all of the information that it has regarding the complaint to any individuals involved in the incident, but that even then, information will still be restricted to those with a need to know, both during and after the investigation. The district will, however, fully implement the anti-retaliation provision of this policy and procedure to protect complainants and witnesses. Targeted person, Bullies, Witnesses, Dates? Question Title * 3. Targeted person, Bullies, Witnesses, Dates? Targeted Person: Name(s) of Bullies: Were there any witnesses (if yes, please provide names): Name of School Adult you have already told (if any): Dates when incident(s) occurred: Times when incident(s) occurred: Did Physical injury result from this incident: Was the targeted person absent from school due to this incident: Where Did the incident(s) happen? Choose all that apply. Question Title * 4. Where Did the incident(s) happen? Choose all that apply. Classroom Lunchroom Hallway Restroom Playground Locker Room Athletic Field Parking Lot School Bus Off School Property Internet Cell Phone Other (please specify) Please check the box that best describes what the bully did. Please choose all that apply. Question Title * 5. Please check the box that best describes what the bully did. Please choose all that apply. Sharing inappropriate drawings/cartoons/photographs/images/notes Cyber bullying (bullying by calling, texting, emailing, web posting, etc.) Spreading harmful rumors or gossip. Hitting, kicking, shoving, spitting, hair pulling or throwing something at the individual. Making rude, threatening and/or critical gestures or remarks. Getting another person to hit or harm the individual. Making the individual fearful, demanding money or exploiting. Putting the individual down and making the individual a target of jokes, teasing, or name calling. Excluding or rejecting the individual—motivated by race, color, religion, ancestry, national origin, cultural, gender, socio-economic status, sexual orientation including gender expression or identity, mental or physical disability or other distinguishing characteristics. Making unwelcomed sexual advances, requests for sexual favors, sexually motivated physical contact or other verbal or physical conduct of a sexual nature. Other (please specify) Why did you think the bullying occurred? Question Title * 6. Why did you think the bullying occurred? Is there any additional information you would like to provide? Question Title * 7. Is there any additional information you would like to provide? Done