B/H/DV Form 1 Page 1 of 3 BREVARD PUBLIC SCHOOLS STUDENT REPORTING FORM For a report of student-related bullying, sexual harassment, other forms of harassment, and teen dating violence and abuse. This form is to be confidentially maintained in accordance with the Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. § 1232g. A student can report bullying or harassment by talking to an adult at school or completing this form and returning it to the dean, assistant principal, or principal. A parent can place this form in the school’s drop off spot for anonymous reporting. If giving an oral report, a school administrator should complete this form. Today’s Date ____/____/_____School______________________________________________________________________ Your Name ___________________________________________________________________________________________ (Please print) Were you an eye witness? No Yes If no, who reported it to you? ____________________________________________________________________________ Who does this involve? _________________________________________________________________________________ What happened? Choose all that apply and describe the exact words or behaviors used under “Other” Teasing Hitting or kicking Gossip and rumors being spread Taunting Name calling Being left out on purpose Made fun of Getting someone in trouble E-mail, Facebook®, text message (Print all messages and attach) Shoving or pushing Other (specify) __________________________________________ Describe what happened (the most recent incident). ______________________________________________________________________________________________________ ________________________________________________________________________ (attach a separate sheet, if necessary) When did this happen? Date: _____________________________________________________________________________ Where did this happen? On school property – (if you check this box list the location at school) ________________________________________ On a school bus At school-sponsored activity or event off school property On the way to / from school Other_____________________________________ What have you done to try to stop his/her behavior? __________________________________________________________ Is there anyone who witnessed this behavior? ________________________________________________________________ How has this incident affected you? ________________________________________________________________________ Have you reported prior problems with this student(s) to a teacher, principal, or other school staff before? No Yes (If yes, who did you report it to?) _______________________________________________________ How many times have issues come up with the same student(s) before this incident? Check most appropriate number of incidents. One (1) Two (2) Three or more (3 or more) (list prior incidents on page 2 of 3) B/H/DV Form 1 Page 2 of 3 Describe the details of incident separate from the incident on page 1 below. Separate incident prior to that found on Page 1: Describe what happened (the second incident). ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ When did this happen? Date: _____________________________________________________________________________ Whom did it involve? ____________________________________________________________________________________ Was there anyone who witnessed this behavior? _____________________________________________________________ Where did this happen? On school property – (if you check this box list the location at school) ________________________________________ On a school bus At school-sponsored activity or event off school property On the way to / from school Other_____________________________________ Did you report the problem to a teacher, principal, or other school staff? No Yes (If yes, who did you report it to?) _______________________________________________________ What did they do to help? ________________________________________________________________________________ Separate incident prior to that found on Page 1 and the above incident: Describe what happened (the third incident). ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ When did this happen? Date: _____________________________________________________________________________ Whom did it involve? ____________________________________________________________________________________ Was there anyone who witnessed this behavior? _____________________________________________________________ Where did this happen? On school property – (if you check this box list the location at school) ________________________________________ On a school bus At school-sponsored activity or event off school property On the way to / from school Other_____________________________________ Did you report the problem to a teacher, principal, or other school staff? No Yes (If yes, who did you report it to?) _______________________________________________________ What did they do to help? ________________________________________________________________________________ B/H/DV Form 1 Page 3 of 3 What would you like us to do to help? ______________________________________________________________________ ______________________________________________________________________________________________________ *You may list any other prior incidents on a separate sheet of paper then attach to this form. _________________________________________________ ____/____/_____ Your Signature Date Thank you. This report will be investigated. If you think you are in danger, please contact a trusted adult right away! …………………………………………………………………………………………………………………………… FOR ADMINISTRATOR USE ONLY Date Received: _______________________ Received By: _______________________________________________________________ Administrative Findings No further action required. Further investigation required. Use Incident Investigation Form 4 Rev. 7/12 VS/PF/BT Student Services This report must be attached to Incident Investigation Form 4