SCES Bully Form | Choctaw County School District

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Choctaw County Schools

107 Tom Orr Drive, Butler, AL 36904

P: 205-459-3031

F: 205-459-3037

Today's Date:

Name of VIctim:

Age of Victim:

Name of Offender:

Age of Offender: (if known)

Is he/she a student?

School of Offender: (if known)

Name of Any Additional Alleged Offender:

Date of Incident:

Additional Date Incident Happened:

Where did Incident Happen?

Place check next to the statement(s) that best describes what happened (Choose all that apply):

Hitting, kicking, shoving, spitting, hair pulling, or throwing something

Coercing another person to hit or harm the student

Repeated teasing, name-calling, making critical remarks, or threatening, in person or by other means

Making rude and/or threatening gestures

Intimidating, bullying, extorting, or exploiting

Spreading harmful rumors or gossip

Electronic Communications (specify below)

Other (specify below)

Did a physical injury result from this incident?

If there was a physical injury, do doctors think there will be permanent effects?

Was the student victim absent from school as a result of this incident?

If yes, how many days was the student victim absent from school as a result of the incident?

Did a psychological injury result from this incident?

What did the alleged offender(s) say or do?

Why did the bullying, harassment or intimidation occur?

Is there any additional information you would like to provide?

107 Tom Orr Drive

Butler, AL 36904
P: 205-459-3031 - F: 205-459-3037

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