Adopted: October 2012
Revised: August 2023
Download 503.8P - Report of Bullying Behavior
District 196 prohibits all forms of bullying and will take action to stop bullying when there is a connection between the bullying and the school environment.
Bullying is defined as intimidating, threatening, abusive or harming conduct that is objectively offensive and (1) there is an actual or perceived imbalance of power between the student engaging in the conduct and the target of the conduct and the conduct is repeated or forms a pattern or (2) materially and substantially interferes with a student’s educational opportunities or performance or ability to participate in school functions or activities or receive school benefits, services or privileges. Bullying includes various forms of conduct, and includes, but is not limited to cyberbullying, sexual exploitation and malicious and sadistic conduct. More information can be found in District Regulation 503.8AR, Bullying Prohibition.
Complete this form if you believe you are a victim of bullying or want to report bullying on another’s behalf.
Your school and grade:
Your name (print):
Your telephone number:
Approximate date(s) and frequency of alleged bullying:
Name of person(s) you believe bullied you or another person:
Name of victim of alleged bullying (if other than you):
List any witnesses who were present when the bullying occurred:
Where did the bullying occur?
Describe the bullying as clearly as possible, including relevant details such as whether the alleged bullying was physical or verbal, and whether any harm or fear of harm resulted from the bullying:
This report is filed based on my honest belief that I am a victim of or witness to bullying. I hereby certify that the information I have provided in this report is true and complete to the best of my knowledge.
Signature of Reporter X Date____
Signature of School Official X Received Date
Print Name of School Official_____________________________________
School District Response to Report of Bullying
(for office use only)
Check one box and complete the corresponding sections:
□ Allegations in this report were investigated and were not substantiated or were found not to meet the definition of “bullying.”
Brief summary of basis for conclusion:
Administrator X Date
□ Allegations in this report were investigated and substantiated.
Brief summary of basis for conclusion:
Corrective action/restorative measures taken including provision of available community resources as appropriate:
Administrator X Date
Parent/guardian of victim and bully were contacted:
Administrator X Date
Two-week follow-up meeting with the victim:
Administrator X Date
Bullying has stopped: Yes □ No □
If no, additional action must be taken per Administrative Regulation 503.8AR, section 5.7.
Comments and/or additional action taken:
This form contains private and/or confidential data and is to be maintained in accordance with the Family Educational Rights and Privacy Act (FERPA) and the Minnesota Government Data Practices Act (MGDPA). It is subject to the school district’s general records retention schedule.
cc: School file